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Tinnitus Patient Management
Robert W Sweetow PhD University of California San Francisco
San Francisco California robertsweetowucsfedu
Tinnitus Facts
bull Approximately 15 of the worldrsquos
population has tinnitus
bull More than 70 of hearing impaired
individuals have had tinnitus at some point
bull 80-90 of tinnitus patients have some
evidence of hearing loss
bull 10 - 20 of tinnitus sufferers seek medical
attention
Progressively
more severe
tinnitus problems
Only education needed
Non-bothersome tinnitus
Population of
all people
who
experience
chronic
tinnitus
Debilitating tinnitus
Dobie 2004
Most common difficulties
attributed to tinnitus
bull Sleep
bull Persistence
bull Speech understanding
bull Despair frustration depression
bull Annoyance
irritation stress
bull Concentration
confusion
bull Drug
dependence
bull Painheadaches
Tyler and Baker 1983
bull Subjective tinnitus
idiopathic
sensory
neural
central
bull Objective tinnitus
vascular
muscular
Some outer and middle ear
pathologies associated with tinnitus
cholesteotoma mastoiditis
otosclerosis otitis media
impacted cerumen allergies
palatal myoclonus headear trauma
patulous eustachian tube
glomus jugulare tumor
abnormal middle ear resonance
Some inner ear
pathologies associated with tinnitus
acoustic trauma presbycusis
noise exposure menierersquos disease
labyrinthitis acoustic neuroma
headear trauma ototoxicity
meningitis perilymph fistula
autoimmune inner ear disease
vestibular schwannoma
sudden hearing loss
Figure 2 Incidence of tinnitus by age group
Kochkin et al 2012
Tinnitus and Hearing Loss
0 5 10 15 20 25 30
HL at 4k Hz
Odds of Having Tinnitus
10-19 dB
20-29 dB
30-39 dB
40-49 dB
50-59 dB
60-69 dB
70-79 dB
gt 80 dB
Correlation between tinnitus
severity and auditory threshold
Tinnitus symptom severity and best
hearing threshold
0
10
20
30
40
50
60
70
80
0 20 40 60 80 100 120
Tinnitus Handicap Inventory Score
Be
st
he
ari
ng
th
res
ho
ld a
t
FR
EQ
ma
x
Tsai Cheung and
Sweetow 2007
Restricted cochlear lesions in adult animals produce a dynamic reorganization of the
representation or map of the cochlea in the primary auditory cortex
AUDITORY CORTEX
LOW
MID
httpwwwsickkidsoncaotolaryngologyEVOKD-PTasp
18 16 14 12 8
6
18 20 24 26 28
14 8
6 1 mm 12
Pre-Lesion
Post-Lesion
Cat Auditory Cortex
Frequency (kHz)
LOW
M I D
LOW MID
HIGH
Irvine and Rajan (1995)
Research supporting central location
bull Heller and Bergman 1953
bull Andersson et al 1997 Baguley et al 1992
(translabyrinthine surgery)hellip
bull Lockwood and Salvi 1998 Burkard 2001(PET)
bull Kaltenbach 2000 (cochlear nucleus
hyperactivity despite cochlear destruction)
bull Zacharek 2002 (sustained DCN acitivity
following noise damaged cochlear ablation)
bull vascular
bull dementia
bull cardiovascular
diseasehypertension
bull blood disease anemia
bull multiple sclerosis
Some central nervous system pathologies associated with tinnitus
Other factors associated
with tinnitus bull temporomandibular disorders
bull cervical misalignment
bull renal disease Alportrsquos kidney
transplants
bull lyme disease
bull zinc deficiency
bull poor circulation
bull hypothyroid hyperthyroid disorders
Psychological contributions
ndash Cognition maladaptive cognitive strategies ldquoThe reaction is the key to whether a person with tinnitus becomes a tinnitus patientrdquo (Sweetow 1986 2000)
ndash Habituation intolerance results from individualrsquos failure to adapt (Hallam et al 1984 2006)
ndash Attention failure to shift attention away from tinnitus (Hallam and McKenna 2006)
ndash Enhanced tinnitus perception is learned response resulting from ldquonegativerdquo emotional reinforcement involving limbic system and autonomic activation (HallumJastreboff and Hazell 1993 McKenna 2004)hellipde-emphasizes connection with peripheral hearing loss
bull caffeine
bull alcohol
bull nicotine
bull sodium
bull high cholesterol hyperlipidemia hyper and hypothryroidism
bull noise exposure
bull stress
Tinnitus exacerbating factors
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
Modern theories of tinnitus origin
bull Disruption of auditory input (eg hearing loss) and resultant increased gain (activity) within the central auditory system (including the dorsal cochlear nucleus and auditory cortex)
bull Decrease in inhibitory (efferent) function
bull Over-representation of edge-frequencies (cortical plasticity)
bull Dysfunctional gating in basal ganglia
bull Other somatosensory influences (cervical disturbances etc)
bull Increased attention related to reticular activating system involvement
bull Association with fear and threat (limbic system)
Summary of Recent Basal Ganglia Theory
Phantom percepts are represented in the central auditory system
Permission to gate phantom percepts for conscious awareness is controlled by the dorsal striatum
Action to attend reject or accept phantom percepts and form perceptual habits is decided by the ventral striatum
Determination of tinnitus distress severity is mediated through the limbic and paralimbic system-nucleus accumbens-ventral striatum loop
Another ldquogatekeepingrdquo theory
bull The linked network of brain structures involved in emotion
behavior and long-term memorymdashacts as a gatekeeper to
keep the tinnitus signal from reaching the auditory cortex
bull Sensory information enters both the auditory and the limbic
systems through the medial geniculate nucleus (MGN)
bull Before the signal is processed it travels through the thalamic
reticular nucleus (TRN) which evaluates whether or not it
should be passed on
bull There is a significant loss of volume in the medial
prefrontal cortex (mPFC) in people with tinnitus This
structure projects into and activates the TRN If the volume
loss creates a loss of neurons the mPFC and TRN will
malfunction
Rauschecker et al Neuron 2010
Tinnitus is associated with abnormal EEG-
patterns showing enhanced activity in the δ
band and reduced activity in the α band (Weisz
Moratti Meinzer Dohrmann amp Elbert 2005)
MEG data indicating that subjects with
tinnitus
lt 4 years have gamma network predominantly
in the temporal cortex but subjects with
tinnitus of a longer duration show a widely
distributed gamma network into the frontal
and parietal regions (deRidder 2011)
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Tinnitus Facts
bull Approximately 15 of the worldrsquos
population has tinnitus
bull More than 70 of hearing impaired
individuals have had tinnitus at some point
bull 80-90 of tinnitus patients have some
evidence of hearing loss
bull 10 - 20 of tinnitus sufferers seek medical
attention
Progressively
more severe
tinnitus problems
Only education needed
Non-bothersome tinnitus
Population of
all people
who
experience
chronic
tinnitus
Debilitating tinnitus
Dobie 2004
Most common difficulties
attributed to tinnitus
bull Sleep
bull Persistence
bull Speech understanding
bull Despair frustration depression
bull Annoyance
irritation stress
bull Concentration
confusion
bull Drug
dependence
bull Painheadaches
Tyler and Baker 1983
bull Subjective tinnitus
idiopathic
sensory
neural
central
bull Objective tinnitus
vascular
muscular
Some outer and middle ear
pathologies associated with tinnitus
cholesteotoma mastoiditis
otosclerosis otitis media
impacted cerumen allergies
palatal myoclonus headear trauma
patulous eustachian tube
glomus jugulare tumor
abnormal middle ear resonance
Some inner ear
pathologies associated with tinnitus
acoustic trauma presbycusis
noise exposure menierersquos disease
labyrinthitis acoustic neuroma
headear trauma ototoxicity
meningitis perilymph fistula
autoimmune inner ear disease
vestibular schwannoma
sudden hearing loss
Figure 2 Incidence of tinnitus by age group
Kochkin et al 2012
Tinnitus and Hearing Loss
0 5 10 15 20 25 30
HL at 4k Hz
Odds of Having Tinnitus
10-19 dB
20-29 dB
30-39 dB
40-49 dB
50-59 dB
60-69 dB
70-79 dB
gt 80 dB
Correlation between tinnitus
severity and auditory threshold
Tinnitus symptom severity and best
hearing threshold
0
10
20
30
40
50
60
70
80
0 20 40 60 80 100 120
Tinnitus Handicap Inventory Score
Be
st
he
ari
ng
th
res
ho
ld a
t
FR
EQ
ma
x
Tsai Cheung and
Sweetow 2007
Restricted cochlear lesions in adult animals produce a dynamic reorganization of the
representation or map of the cochlea in the primary auditory cortex
AUDITORY CORTEX
LOW
MID
httpwwwsickkidsoncaotolaryngologyEVOKD-PTasp
18 16 14 12 8
6
18 20 24 26 28
14 8
6 1 mm 12
Pre-Lesion
Post-Lesion
Cat Auditory Cortex
Frequency (kHz)
LOW
M I D
LOW MID
HIGH
Irvine and Rajan (1995)
Research supporting central location
bull Heller and Bergman 1953
bull Andersson et al 1997 Baguley et al 1992
(translabyrinthine surgery)hellip
bull Lockwood and Salvi 1998 Burkard 2001(PET)
bull Kaltenbach 2000 (cochlear nucleus
hyperactivity despite cochlear destruction)
bull Zacharek 2002 (sustained DCN acitivity
following noise damaged cochlear ablation)
bull vascular
bull dementia
bull cardiovascular
diseasehypertension
bull blood disease anemia
bull multiple sclerosis
Some central nervous system pathologies associated with tinnitus
Other factors associated
with tinnitus bull temporomandibular disorders
bull cervical misalignment
bull renal disease Alportrsquos kidney
transplants
bull lyme disease
bull zinc deficiency
bull poor circulation
bull hypothyroid hyperthyroid disorders
Psychological contributions
ndash Cognition maladaptive cognitive strategies ldquoThe reaction is the key to whether a person with tinnitus becomes a tinnitus patientrdquo (Sweetow 1986 2000)
ndash Habituation intolerance results from individualrsquos failure to adapt (Hallam et al 1984 2006)
ndash Attention failure to shift attention away from tinnitus (Hallam and McKenna 2006)
ndash Enhanced tinnitus perception is learned response resulting from ldquonegativerdquo emotional reinforcement involving limbic system and autonomic activation (HallumJastreboff and Hazell 1993 McKenna 2004)hellipde-emphasizes connection with peripheral hearing loss
bull caffeine
bull alcohol
bull nicotine
bull sodium
bull high cholesterol hyperlipidemia hyper and hypothryroidism
bull noise exposure
bull stress
Tinnitus exacerbating factors
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
Modern theories of tinnitus origin
bull Disruption of auditory input (eg hearing loss) and resultant increased gain (activity) within the central auditory system (including the dorsal cochlear nucleus and auditory cortex)
bull Decrease in inhibitory (efferent) function
bull Over-representation of edge-frequencies (cortical plasticity)
bull Dysfunctional gating in basal ganglia
bull Other somatosensory influences (cervical disturbances etc)
bull Increased attention related to reticular activating system involvement
bull Association with fear and threat (limbic system)
Summary of Recent Basal Ganglia Theory
Phantom percepts are represented in the central auditory system
Permission to gate phantom percepts for conscious awareness is controlled by the dorsal striatum
Action to attend reject or accept phantom percepts and form perceptual habits is decided by the ventral striatum
Determination of tinnitus distress severity is mediated through the limbic and paralimbic system-nucleus accumbens-ventral striatum loop
Another ldquogatekeepingrdquo theory
bull The linked network of brain structures involved in emotion
behavior and long-term memorymdashacts as a gatekeeper to
keep the tinnitus signal from reaching the auditory cortex
bull Sensory information enters both the auditory and the limbic
systems through the medial geniculate nucleus (MGN)
bull Before the signal is processed it travels through the thalamic
reticular nucleus (TRN) which evaluates whether or not it
should be passed on
bull There is a significant loss of volume in the medial
prefrontal cortex (mPFC) in people with tinnitus This
structure projects into and activates the TRN If the volume
loss creates a loss of neurons the mPFC and TRN will
malfunction
Rauschecker et al Neuron 2010
Tinnitus is associated with abnormal EEG-
patterns showing enhanced activity in the δ
band and reduced activity in the α band (Weisz
Moratti Meinzer Dohrmann amp Elbert 2005)
MEG data indicating that subjects with
tinnitus
lt 4 years have gamma network predominantly
in the temporal cortex but subjects with
tinnitus of a longer duration show a widely
distributed gamma network into the frontal
and parietal regions (deRidder 2011)
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Progressively
more severe
tinnitus problems
Only education needed
Non-bothersome tinnitus
Population of
all people
who
experience
chronic
tinnitus
Debilitating tinnitus
Dobie 2004
Most common difficulties
attributed to tinnitus
bull Sleep
bull Persistence
bull Speech understanding
bull Despair frustration depression
bull Annoyance
irritation stress
bull Concentration
confusion
bull Drug
dependence
bull Painheadaches
Tyler and Baker 1983
bull Subjective tinnitus
idiopathic
sensory
neural
central
bull Objective tinnitus
vascular
muscular
Some outer and middle ear
pathologies associated with tinnitus
cholesteotoma mastoiditis
otosclerosis otitis media
impacted cerumen allergies
palatal myoclonus headear trauma
patulous eustachian tube
glomus jugulare tumor
abnormal middle ear resonance
Some inner ear
pathologies associated with tinnitus
acoustic trauma presbycusis
noise exposure menierersquos disease
labyrinthitis acoustic neuroma
headear trauma ototoxicity
meningitis perilymph fistula
autoimmune inner ear disease
vestibular schwannoma
sudden hearing loss
Figure 2 Incidence of tinnitus by age group
Kochkin et al 2012
Tinnitus and Hearing Loss
0 5 10 15 20 25 30
HL at 4k Hz
Odds of Having Tinnitus
10-19 dB
20-29 dB
30-39 dB
40-49 dB
50-59 dB
60-69 dB
70-79 dB
gt 80 dB
Correlation between tinnitus
severity and auditory threshold
Tinnitus symptom severity and best
hearing threshold
0
10
20
30
40
50
60
70
80
0 20 40 60 80 100 120
Tinnitus Handicap Inventory Score
Be
st
he
ari
ng
th
res
ho
ld a
t
FR
EQ
ma
x
Tsai Cheung and
Sweetow 2007
Restricted cochlear lesions in adult animals produce a dynamic reorganization of the
representation or map of the cochlea in the primary auditory cortex
AUDITORY CORTEX
LOW
MID
httpwwwsickkidsoncaotolaryngologyEVOKD-PTasp
18 16 14 12 8
6
18 20 24 26 28
14 8
6 1 mm 12
Pre-Lesion
Post-Lesion
Cat Auditory Cortex
Frequency (kHz)
LOW
M I D
LOW MID
HIGH
Irvine and Rajan (1995)
Research supporting central location
bull Heller and Bergman 1953
bull Andersson et al 1997 Baguley et al 1992
(translabyrinthine surgery)hellip
bull Lockwood and Salvi 1998 Burkard 2001(PET)
bull Kaltenbach 2000 (cochlear nucleus
hyperactivity despite cochlear destruction)
bull Zacharek 2002 (sustained DCN acitivity
following noise damaged cochlear ablation)
bull vascular
bull dementia
bull cardiovascular
diseasehypertension
bull blood disease anemia
bull multiple sclerosis
Some central nervous system pathologies associated with tinnitus
Other factors associated
with tinnitus bull temporomandibular disorders
bull cervical misalignment
bull renal disease Alportrsquos kidney
transplants
bull lyme disease
bull zinc deficiency
bull poor circulation
bull hypothyroid hyperthyroid disorders
Psychological contributions
ndash Cognition maladaptive cognitive strategies ldquoThe reaction is the key to whether a person with tinnitus becomes a tinnitus patientrdquo (Sweetow 1986 2000)
ndash Habituation intolerance results from individualrsquos failure to adapt (Hallam et al 1984 2006)
ndash Attention failure to shift attention away from tinnitus (Hallam and McKenna 2006)
ndash Enhanced tinnitus perception is learned response resulting from ldquonegativerdquo emotional reinforcement involving limbic system and autonomic activation (HallumJastreboff and Hazell 1993 McKenna 2004)hellipde-emphasizes connection with peripheral hearing loss
bull caffeine
bull alcohol
bull nicotine
bull sodium
bull high cholesterol hyperlipidemia hyper and hypothryroidism
bull noise exposure
bull stress
Tinnitus exacerbating factors
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
Modern theories of tinnitus origin
bull Disruption of auditory input (eg hearing loss) and resultant increased gain (activity) within the central auditory system (including the dorsal cochlear nucleus and auditory cortex)
bull Decrease in inhibitory (efferent) function
bull Over-representation of edge-frequencies (cortical plasticity)
bull Dysfunctional gating in basal ganglia
bull Other somatosensory influences (cervical disturbances etc)
bull Increased attention related to reticular activating system involvement
bull Association with fear and threat (limbic system)
Summary of Recent Basal Ganglia Theory
Phantom percepts are represented in the central auditory system
Permission to gate phantom percepts for conscious awareness is controlled by the dorsal striatum
Action to attend reject or accept phantom percepts and form perceptual habits is decided by the ventral striatum
Determination of tinnitus distress severity is mediated through the limbic and paralimbic system-nucleus accumbens-ventral striatum loop
Another ldquogatekeepingrdquo theory
bull The linked network of brain structures involved in emotion
behavior and long-term memorymdashacts as a gatekeeper to
keep the tinnitus signal from reaching the auditory cortex
bull Sensory information enters both the auditory and the limbic
systems through the medial geniculate nucleus (MGN)
bull Before the signal is processed it travels through the thalamic
reticular nucleus (TRN) which evaluates whether or not it
should be passed on
bull There is a significant loss of volume in the medial
prefrontal cortex (mPFC) in people with tinnitus This
structure projects into and activates the TRN If the volume
loss creates a loss of neurons the mPFC and TRN will
malfunction
Rauschecker et al Neuron 2010
Tinnitus is associated with abnormal EEG-
patterns showing enhanced activity in the δ
band and reduced activity in the α band (Weisz
Moratti Meinzer Dohrmann amp Elbert 2005)
MEG data indicating that subjects with
tinnitus
lt 4 years have gamma network predominantly
in the temporal cortex but subjects with
tinnitus of a longer duration show a widely
distributed gamma network into the frontal
and parietal regions (deRidder 2011)
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Most common difficulties
attributed to tinnitus
bull Sleep
bull Persistence
bull Speech understanding
bull Despair frustration depression
bull Annoyance
irritation stress
bull Concentration
confusion
bull Drug
dependence
bull Painheadaches
Tyler and Baker 1983
bull Subjective tinnitus
idiopathic
sensory
neural
central
bull Objective tinnitus
vascular
muscular
Some outer and middle ear
pathologies associated with tinnitus
cholesteotoma mastoiditis
otosclerosis otitis media
impacted cerumen allergies
palatal myoclonus headear trauma
patulous eustachian tube
glomus jugulare tumor
abnormal middle ear resonance
Some inner ear
pathologies associated with tinnitus
acoustic trauma presbycusis
noise exposure menierersquos disease
labyrinthitis acoustic neuroma
headear trauma ototoxicity
meningitis perilymph fistula
autoimmune inner ear disease
vestibular schwannoma
sudden hearing loss
Figure 2 Incidence of tinnitus by age group
Kochkin et al 2012
Tinnitus and Hearing Loss
0 5 10 15 20 25 30
HL at 4k Hz
Odds of Having Tinnitus
10-19 dB
20-29 dB
30-39 dB
40-49 dB
50-59 dB
60-69 dB
70-79 dB
gt 80 dB
Correlation between tinnitus
severity and auditory threshold
Tinnitus symptom severity and best
hearing threshold
0
10
20
30
40
50
60
70
80
0 20 40 60 80 100 120
Tinnitus Handicap Inventory Score
Be
st
he
ari
ng
th
res
ho
ld a
t
FR
EQ
ma
x
Tsai Cheung and
Sweetow 2007
Restricted cochlear lesions in adult animals produce a dynamic reorganization of the
representation or map of the cochlea in the primary auditory cortex
AUDITORY CORTEX
LOW
MID
httpwwwsickkidsoncaotolaryngologyEVOKD-PTasp
18 16 14 12 8
6
18 20 24 26 28
14 8
6 1 mm 12
Pre-Lesion
Post-Lesion
Cat Auditory Cortex
Frequency (kHz)
LOW
M I D
LOW MID
HIGH
Irvine and Rajan (1995)
Research supporting central location
bull Heller and Bergman 1953
bull Andersson et al 1997 Baguley et al 1992
(translabyrinthine surgery)hellip
bull Lockwood and Salvi 1998 Burkard 2001(PET)
bull Kaltenbach 2000 (cochlear nucleus
hyperactivity despite cochlear destruction)
bull Zacharek 2002 (sustained DCN acitivity
following noise damaged cochlear ablation)
bull vascular
bull dementia
bull cardiovascular
diseasehypertension
bull blood disease anemia
bull multiple sclerosis
Some central nervous system pathologies associated with tinnitus
Other factors associated
with tinnitus bull temporomandibular disorders
bull cervical misalignment
bull renal disease Alportrsquos kidney
transplants
bull lyme disease
bull zinc deficiency
bull poor circulation
bull hypothyroid hyperthyroid disorders
Psychological contributions
ndash Cognition maladaptive cognitive strategies ldquoThe reaction is the key to whether a person with tinnitus becomes a tinnitus patientrdquo (Sweetow 1986 2000)
ndash Habituation intolerance results from individualrsquos failure to adapt (Hallam et al 1984 2006)
ndash Attention failure to shift attention away from tinnitus (Hallam and McKenna 2006)
ndash Enhanced tinnitus perception is learned response resulting from ldquonegativerdquo emotional reinforcement involving limbic system and autonomic activation (HallumJastreboff and Hazell 1993 McKenna 2004)hellipde-emphasizes connection with peripheral hearing loss
bull caffeine
bull alcohol
bull nicotine
bull sodium
bull high cholesterol hyperlipidemia hyper and hypothryroidism
bull noise exposure
bull stress
Tinnitus exacerbating factors
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
Modern theories of tinnitus origin
bull Disruption of auditory input (eg hearing loss) and resultant increased gain (activity) within the central auditory system (including the dorsal cochlear nucleus and auditory cortex)
bull Decrease in inhibitory (efferent) function
bull Over-representation of edge-frequencies (cortical plasticity)
bull Dysfunctional gating in basal ganglia
bull Other somatosensory influences (cervical disturbances etc)
bull Increased attention related to reticular activating system involvement
bull Association with fear and threat (limbic system)
Summary of Recent Basal Ganglia Theory
Phantom percepts are represented in the central auditory system
Permission to gate phantom percepts for conscious awareness is controlled by the dorsal striatum
Action to attend reject or accept phantom percepts and form perceptual habits is decided by the ventral striatum
Determination of tinnitus distress severity is mediated through the limbic and paralimbic system-nucleus accumbens-ventral striatum loop
Another ldquogatekeepingrdquo theory
bull The linked network of brain structures involved in emotion
behavior and long-term memorymdashacts as a gatekeeper to
keep the tinnitus signal from reaching the auditory cortex
bull Sensory information enters both the auditory and the limbic
systems through the medial geniculate nucleus (MGN)
bull Before the signal is processed it travels through the thalamic
reticular nucleus (TRN) which evaluates whether or not it
should be passed on
bull There is a significant loss of volume in the medial
prefrontal cortex (mPFC) in people with tinnitus This
structure projects into and activates the TRN If the volume
loss creates a loss of neurons the mPFC and TRN will
malfunction
Rauschecker et al Neuron 2010
Tinnitus is associated with abnormal EEG-
patterns showing enhanced activity in the δ
band and reduced activity in the α band (Weisz
Moratti Meinzer Dohrmann amp Elbert 2005)
MEG data indicating that subjects with
tinnitus
lt 4 years have gamma network predominantly
in the temporal cortex but subjects with
tinnitus of a longer duration show a widely
distributed gamma network into the frontal
and parietal regions (deRidder 2011)
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
bull Subjective tinnitus
idiopathic
sensory
neural
central
bull Objective tinnitus
vascular
muscular
Some outer and middle ear
pathologies associated with tinnitus
cholesteotoma mastoiditis
otosclerosis otitis media
impacted cerumen allergies
palatal myoclonus headear trauma
patulous eustachian tube
glomus jugulare tumor
abnormal middle ear resonance
Some inner ear
pathologies associated with tinnitus
acoustic trauma presbycusis
noise exposure menierersquos disease
labyrinthitis acoustic neuroma
headear trauma ototoxicity
meningitis perilymph fistula
autoimmune inner ear disease
vestibular schwannoma
sudden hearing loss
Figure 2 Incidence of tinnitus by age group
Kochkin et al 2012
Tinnitus and Hearing Loss
0 5 10 15 20 25 30
HL at 4k Hz
Odds of Having Tinnitus
10-19 dB
20-29 dB
30-39 dB
40-49 dB
50-59 dB
60-69 dB
70-79 dB
gt 80 dB
Correlation between tinnitus
severity and auditory threshold
Tinnitus symptom severity and best
hearing threshold
0
10
20
30
40
50
60
70
80
0 20 40 60 80 100 120
Tinnitus Handicap Inventory Score
Be
st
he
ari
ng
th
res
ho
ld a
t
FR
EQ
ma
x
Tsai Cheung and
Sweetow 2007
Restricted cochlear lesions in adult animals produce a dynamic reorganization of the
representation or map of the cochlea in the primary auditory cortex
AUDITORY CORTEX
LOW
MID
httpwwwsickkidsoncaotolaryngologyEVOKD-PTasp
18 16 14 12 8
6
18 20 24 26 28
14 8
6 1 mm 12
Pre-Lesion
Post-Lesion
Cat Auditory Cortex
Frequency (kHz)
LOW
M I D
LOW MID
HIGH
Irvine and Rajan (1995)
Research supporting central location
bull Heller and Bergman 1953
bull Andersson et al 1997 Baguley et al 1992
(translabyrinthine surgery)hellip
bull Lockwood and Salvi 1998 Burkard 2001(PET)
bull Kaltenbach 2000 (cochlear nucleus
hyperactivity despite cochlear destruction)
bull Zacharek 2002 (sustained DCN acitivity
following noise damaged cochlear ablation)
bull vascular
bull dementia
bull cardiovascular
diseasehypertension
bull blood disease anemia
bull multiple sclerosis
Some central nervous system pathologies associated with tinnitus
Other factors associated
with tinnitus bull temporomandibular disorders
bull cervical misalignment
bull renal disease Alportrsquos kidney
transplants
bull lyme disease
bull zinc deficiency
bull poor circulation
bull hypothyroid hyperthyroid disorders
Psychological contributions
ndash Cognition maladaptive cognitive strategies ldquoThe reaction is the key to whether a person with tinnitus becomes a tinnitus patientrdquo (Sweetow 1986 2000)
ndash Habituation intolerance results from individualrsquos failure to adapt (Hallam et al 1984 2006)
ndash Attention failure to shift attention away from tinnitus (Hallam and McKenna 2006)
ndash Enhanced tinnitus perception is learned response resulting from ldquonegativerdquo emotional reinforcement involving limbic system and autonomic activation (HallumJastreboff and Hazell 1993 McKenna 2004)hellipde-emphasizes connection with peripheral hearing loss
bull caffeine
bull alcohol
bull nicotine
bull sodium
bull high cholesterol hyperlipidemia hyper and hypothryroidism
bull noise exposure
bull stress
Tinnitus exacerbating factors
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
Modern theories of tinnitus origin
bull Disruption of auditory input (eg hearing loss) and resultant increased gain (activity) within the central auditory system (including the dorsal cochlear nucleus and auditory cortex)
bull Decrease in inhibitory (efferent) function
bull Over-representation of edge-frequencies (cortical plasticity)
bull Dysfunctional gating in basal ganglia
bull Other somatosensory influences (cervical disturbances etc)
bull Increased attention related to reticular activating system involvement
bull Association with fear and threat (limbic system)
Summary of Recent Basal Ganglia Theory
Phantom percepts are represented in the central auditory system
Permission to gate phantom percepts for conscious awareness is controlled by the dorsal striatum
Action to attend reject or accept phantom percepts and form perceptual habits is decided by the ventral striatum
Determination of tinnitus distress severity is mediated through the limbic and paralimbic system-nucleus accumbens-ventral striatum loop
Another ldquogatekeepingrdquo theory
bull The linked network of brain structures involved in emotion
behavior and long-term memorymdashacts as a gatekeeper to
keep the tinnitus signal from reaching the auditory cortex
bull Sensory information enters both the auditory and the limbic
systems through the medial geniculate nucleus (MGN)
bull Before the signal is processed it travels through the thalamic
reticular nucleus (TRN) which evaluates whether or not it
should be passed on
bull There is a significant loss of volume in the medial
prefrontal cortex (mPFC) in people with tinnitus This
structure projects into and activates the TRN If the volume
loss creates a loss of neurons the mPFC and TRN will
malfunction
Rauschecker et al Neuron 2010
Tinnitus is associated with abnormal EEG-
patterns showing enhanced activity in the δ
band and reduced activity in the α band (Weisz
Moratti Meinzer Dohrmann amp Elbert 2005)
MEG data indicating that subjects with
tinnitus
lt 4 years have gamma network predominantly
in the temporal cortex but subjects with
tinnitus of a longer duration show a widely
distributed gamma network into the frontal
and parietal regions (deRidder 2011)
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Some outer and middle ear
pathologies associated with tinnitus
cholesteotoma mastoiditis
otosclerosis otitis media
impacted cerumen allergies
palatal myoclonus headear trauma
patulous eustachian tube
glomus jugulare tumor
abnormal middle ear resonance
Some inner ear
pathologies associated with tinnitus
acoustic trauma presbycusis
noise exposure menierersquos disease
labyrinthitis acoustic neuroma
headear trauma ototoxicity
meningitis perilymph fistula
autoimmune inner ear disease
vestibular schwannoma
sudden hearing loss
Figure 2 Incidence of tinnitus by age group
Kochkin et al 2012
Tinnitus and Hearing Loss
0 5 10 15 20 25 30
HL at 4k Hz
Odds of Having Tinnitus
10-19 dB
20-29 dB
30-39 dB
40-49 dB
50-59 dB
60-69 dB
70-79 dB
gt 80 dB
Correlation between tinnitus
severity and auditory threshold
Tinnitus symptom severity and best
hearing threshold
0
10
20
30
40
50
60
70
80
0 20 40 60 80 100 120
Tinnitus Handicap Inventory Score
Be
st
he
ari
ng
th
res
ho
ld a
t
FR
EQ
ma
x
Tsai Cheung and
Sweetow 2007
Restricted cochlear lesions in adult animals produce a dynamic reorganization of the
representation or map of the cochlea in the primary auditory cortex
AUDITORY CORTEX
LOW
MID
httpwwwsickkidsoncaotolaryngologyEVOKD-PTasp
18 16 14 12 8
6
18 20 24 26 28
14 8
6 1 mm 12
Pre-Lesion
Post-Lesion
Cat Auditory Cortex
Frequency (kHz)
LOW
M I D
LOW MID
HIGH
Irvine and Rajan (1995)
Research supporting central location
bull Heller and Bergman 1953
bull Andersson et al 1997 Baguley et al 1992
(translabyrinthine surgery)hellip
bull Lockwood and Salvi 1998 Burkard 2001(PET)
bull Kaltenbach 2000 (cochlear nucleus
hyperactivity despite cochlear destruction)
bull Zacharek 2002 (sustained DCN acitivity
following noise damaged cochlear ablation)
bull vascular
bull dementia
bull cardiovascular
diseasehypertension
bull blood disease anemia
bull multiple sclerosis
Some central nervous system pathologies associated with tinnitus
Other factors associated
with tinnitus bull temporomandibular disorders
bull cervical misalignment
bull renal disease Alportrsquos kidney
transplants
bull lyme disease
bull zinc deficiency
bull poor circulation
bull hypothyroid hyperthyroid disorders
Psychological contributions
ndash Cognition maladaptive cognitive strategies ldquoThe reaction is the key to whether a person with tinnitus becomes a tinnitus patientrdquo (Sweetow 1986 2000)
ndash Habituation intolerance results from individualrsquos failure to adapt (Hallam et al 1984 2006)
ndash Attention failure to shift attention away from tinnitus (Hallam and McKenna 2006)
ndash Enhanced tinnitus perception is learned response resulting from ldquonegativerdquo emotional reinforcement involving limbic system and autonomic activation (HallumJastreboff and Hazell 1993 McKenna 2004)hellipde-emphasizes connection with peripheral hearing loss
bull caffeine
bull alcohol
bull nicotine
bull sodium
bull high cholesterol hyperlipidemia hyper and hypothryroidism
bull noise exposure
bull stress
Tinnitus exacerbating factors
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
Modern theories of tinnitus origin
bull Disruption of auditory input (eg hearing loss) and resultant increased gain (activity) within the central auditory system (including the dorsal cochlear nucleus and auditory cortex)
bull Decrease in inhibitory (efferent) function
bull Over-representation of edge-frequencies (cortical plasticity)
bull Dysfunctional gating in basal ganglia
bull Other somatosensory influences (cervical disturbances etc)
bull Increased attention related to reticular activating system involvement
bull Association with fear and threat (limbic system)
Summary of Recent Basal Ganglia Theory
Phantom percepts are represented in the central auditory system
Permission to gate phantom percepts for conscious awareness is controlled by the dorsal striatum
Action to attend reject or accept phantom percepts and form perceptual habits is decided by the ventral striatum
Determination of tinnitus distress severity is mediated through the limbic and paralimbic system-nucleus accumbens-ventral striatum loop
Another ldquogatekeepingrdquo theory
bull The linked network of brain structures involved in emotion
behavior and long-term memorymdashacts as a gatekeeper to
keep the tinnitus signal from reaching the auditory cortex
bull Sensory information enters both the auditory and the limbic
systems through the medial geniculate nucleus (MGN)
bull Before the signal is processed it travels through the thalamic
reticular nucleus (TRN) which evaluates whether or not it
should be passed on
bull There is a significant loss of volume in the medial
prefrontal cortex (mPFC) in people with tinnitus This
structure projects into and activates the TRN If the volume
loss creates a loss of neurons the mPFC and TRN will
malfunction
Rauschecker et al Neuron 2010
Tinnitus is associated with abnormal EEG-
patterns showing enhanced activity in the δ
band and reduced activity in the α band (Weisz
Moratti Meinzer Dohrmann amp Elbert 2005)
MEG data indicating that subjects with
tinnitus
lt 4 years have gamma network predominantly
in the temporal cortex but subjects with
tinnitus of a longer duration show a widely
distributed gamma network into the frontal
and parietal regions (deRidder 2011)
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Some inner ear
pathologies associated with tinnitus
acoustic trauma presbycusis
noise exposure menierersquos disease
labyrinthitis acoustic neuroma
headear trauma ototoxicity
meningitis perilymph fistula
autoimmune inner ear disease
vestibular schwannoma
sudden hearing loss
Figure 2 Incidence of tinnitus by age group
Kochkin et al 2012
Tinnitus and Hearing Loss
0 5 10 15 20 25 30
HL at 4k Hz
Odds of Having Tinnitus
10-19 dB
20-29 dB
30-39 dB
40-49 dB
50-59 dB
60-69 dB
70-79 dB
gt 80 dB
Correlation between tinnitus
severity and auditory threshold
Tinnitus symptom severity and best
hearing threshold
0
10
20
30
40
50
60
70
80
0 20 40 60 80 100 120
Tinnitus Handicap Inventory Score
Be
st
he
ari
ng
th
res
ho
ld a
t
FR
EQ
ma
x
Tsai Cheung and
Sweetow 2007
Restricted cochlear lesions in adult animals produce a dynamic reorganization of the
representation or map of the cochlea in the primary auditory cortex
AUDITORY CORTEX
LOW
MID
httpwwwsickkidsoncaotolaryngologyEVOKD-PTasp
18 16 14 12 8
6
18 20 24 26 28
14 8
6 1 mm 12
Pre-Lesion
Post-Lesion
Cat Auditory Cortex
Frequency (kHz)
LOW
M I D
LOW MID
HIGH
Irvine and Rajan (1995)
Research supporting central location
bull Heller and Bergman 1953
bull Andersson et al 1997 Baguley et al 1992
(translabyrinthine surgery)hellip
bull Lockwood and Salvi 1998 Burkard 2001(PET)
bull Kaltenbach 2000 (cochlear nucleus
hyperactivity despite cochlear destruction)
bull Zacharek 2002 (sustained DCN acitivity
following noise damaged cochlear ablation)
bull vascular
bull dementia
bull cardiovascular
diseasehypertension
bull blood disease anemia
bull multiple sclerosis
Some central nervous system pathologies associated with tinnitus
Other factors associated
with tinnitus bull temporomandibular disorders
bull cervical misalignment
bull renal disease Alportrsquos kidney
transplants
bull lyme disease
bull zinc deficiency
bull poor circulation
bull hypothyroid hyperthyroid disorders
Psychological contributions
ndash Cognition maladaptive cognitive strategies ldquoThe reaction is the key to whether a person with tinnitus becomes a tinnitus patientrdquo (Sweetow 1986 2000)
ndash Habituation intolerance results from individualrsquos failure to adapt (Hallam et al 1984 2006)
ndash Attention failure to shift attention away from tinnitus (Hallam and McKenna 2006)
ndash Enhanced tinnitus perception is learned response resulting from ldquonegativerdquo emotional reinforcement involving limbic system and autonomic activation (HallumJastreboff and Hazell 1993 McKenna 2004)hellipde-emphasizes connection with peripheral hearing loss
bull caffeine
bull alcohol
bull nicotine
bull sodium
bull high cholesterol hyperlipidemia hyper and hypothryroidism
bull noise exposure
bull stress
Tinnitus exacerbating factors
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
Modern theories of tinnitus origin
bull Disruption of auditory input (eg hearing loss) and resultant increased gain (activity) within the central auditory system (including the dorsal cochlear nucleus and auditory cortex)
bull Decrease in inhibitory (efferent) function
bull Over-representation of edge-frequencies (cortical plasticity)
bull Dysfunctional gating in basal ganglia
bull Other somatosensory influences (cervical disturbances etc)
bull Increased attention related to reticular activating system involvement
bull Association with fear and threat (limbic system)
Summary of Recent Basal Ganglia Theory
Phantom percepts are represented in the central auditory system
Permission to gate phantom percepts for conscious awareness is controlled by the dorsal striatum
Action to attend reject or accept phantom percepts and form perceptual habits is decided by the ventral striatum
Determination of tinnitus distress severity is mediated through the limbic and paralimbic system-nucleus accumbens-ventral striatum loop
Another ldquogatekeepingrdquo theory
bull The linked network of brain structures involved in emotion
behavior and long-term memorymdashacts as a gatekeeper to
keep the tinnitus signal from reaching the auditory cortex
bull Sensory information enters both the auditory and the limbic
systems through the medial geniculate nucleus (MGN)
bull Before the signal is processed it travels through the thalamic
reticular nucleus (TRN) which evaluates whether or not it
should be passed on
bull There is a significant loss of volume in the medial
prefrontal cortex (mPFC) in people with tinnitus This
structure projects into and activates the TRN If the volume
loss creates a loss of neurons the mPFC and TRN will
malfunction
Rauschecker et al Neuron 2010
Tinnitus is associated with abnormal EEG-
patterns showing enhanced activity in the δ
band and reduced activity in the α band (Weisz
Moratti Meinzer Dohrmann amp Elbert 2005)
MEG data indicating that subjects with
tinnitus
lt 4 years have gamma network predominantly
in the temporal cortex but subjects with
tinnitus of a longer duration show a widely
distributed gamma network into the frontal
and parietal regions (deRidder 2011)
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Figure 2 Incidence of tinnitus by age group
Kochkin et al 2012
Tinnitus and Hearing Loss
0 5 10 15 20 25 30
HL at 4k Hz
Odds of Having Tinnitus
10-19 dB
20-29 dB
30-39 dB
40-49 dB
50-59 dB
60-69 dB
70-79 dB
gt 80 dB
Correlation between tinnitus
severity and auditory threshold
Tinnitus symptom severity and best
hearing threshold
0
10
20
30
40
50
60
70
80
0 20 40 60 80 100 120
Tinnitus Handicap Inventory Score
Be
st
he
ari
ng
th
res
ho
ld a
t
FR
EQ
ma
x
Tsai Cheung and
Sweetow 2007
Restricted cochlear lesions in adult animals produce a dynamic reorganization of the
representation or map of the cochlea in the primary auditory cortex
AUDITORY CORTEX
LOW
MID
httpwwwsickkidsoncaotolaryngologyEVOKD-PTasp
18 16 14 12 8
6
18 20 24 26 28
14 8
6 1 mm 12
Pre-Lesion
Post-Lesion
Cat Auditory Cortex
Frequency (kHz)
LOW
M I D
LOW MID
HIGH
Irvine and Rajan (1995)
Research supporting central location
bull Heller and Bergman 1953
bull Andersson et al 1997 Baguley et al 1992
(translabyrinthine surgery)hellip
bull Lockwood and Salvi 1998 Burkard 2001(PET)
bull Kaltenbach 2000 (cochlear nucleus
hyperactivity despite cochlear destruction)
bull Zacharek 2002 (sustained DCN acitivity
following noise damaged cochlear ablation)
bull vascular
bull dementia
bull cardiovascular
diseasehypertension
bull blood disease anemia
bull multiple sclerosis
Some central nervous system pathologies associated with tinnitus
Other factors associated
with tinnitus bull temporomandibular disorders
bull cervical misalignment
bull renal disease Alportrsquos kidney
transplants
bull lyme disease
bull zinc deficiency
bull poor circulation
bull hypothyroid hyperthyroid disorders
Psychological contributions
ndash Cognition maladaptive cognitive strategies ldquoThe reaction is the key to whether a person with tinnitus becomes a tinnitus patientrdquo (Sweetow 1986 2000)
ndash Habituation intolerance results from individualrsquos failure to adapt (Hallam et al 1984 2006)
ndash Attention failure to shift attention away from tinnitus (Hallam and McKenna 2006)
ndash Enhanced tinnitus perception is learned response resulting from ldquonegativerdquo emotional reinforcement involving limbic system and autonomic activation (HallumJastreboff and Hazell 1993 McKenna 2004)hellipde-emphasizes connection with peripheral hearing loss
bull caffeine
bull alcohol
bull nicotine
bull sodium
bull high cholesterol hyperlipidemia hyper and hypothryroidism
bull noise exposure
bull stress
Tinnitus exacerbating factors
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
Modern theories of tinnitus origin
bull Disruption of auditory input (eg hearing loss) and resultant increased gain (activity) within the central auditory system (including the dorsal cochlear nucleus and auditory cortex)
bull Decrease in inhibitory (efferent) function
bull Over-representation of edge-frequencies (cortical plasticity)
bull Dysfunctional gating in basal ganglia
bull Other somatosensory influences (cervical disturbances etc)
bull Increased attention related to reticular activating system involvement
bull Association with fear and threat (limbic system)
Summary of Recent Basal Ganglia Theory
Phantom percepts are represented in the central auditory system
Permission to gate phantom percepts for conscious awareness is controlled by the dorsal striatum
Action to attend reject or accept phantom percepts and form perceptual habits is decided by the ventral striatum
Determination of tinnitus distress severity is mediated through the limbic and paralimbic system-nucleus accumbens-ventral striatum loop
Another ldquogatekeepingrdquo theory
bull The linked network of brain structures involved in emotion
behavior and long-term memorymdashacts as a gatekeeper to
keep the tinnitus signal from reaching the auditory cortex
bull Sensory information enters both the auditory and the limbic
systems through the medial geniculate nucleus (MGN)
bull Before the signal is processed it travels through the thalamic
reticular nucleus (TRN) which evaluates whether or not it
should be passed on
bull There is a significant loss of volume in the medial
prefrontal cortex (mPFC) in people with tinnitus This
structure projects into and activates the TRN If the volume
loss creates a loss of neurons the mPFC and TRN will
malfunction
Rauschecker et al Neuron 2010
Tinnitus is associated with abnormal EEG-
patterns showing enhanced activity in the δ
band and reduced activity in the α band (Weisz
Moratti Meinzer Dohrmann amp Elbert 2005)
MEG data indicating that subjects with
tinnitus
lt 4 years have gamma network predominantly
in the temporal cortex but subjects with
tinnitus of a longer duration show a widely
distributed gamma network into the frontal
and parietal regions (deRidder 2011)
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Tinnitus and Hearing Loss
0 5 10 15 20 25 30
HL at 4k Hz
Odds of Having Tinnitus
10-19 dB
20-29 dB
30-39 dB
40-49 dB
50-59 dB
60-69 dB
70-79 dB
gt 80 dB
Correlation between tinnitus
severity and auditory threshold
Tinnitus symptom severity and best
hearing threshold
0
10
20
30
40
50
60
70
80
0 20 40 60 80 100 120
Tinnitus Handicap Inventory Score
Be
st
he
ari
ng
th
res
ho
ld a
t
FR
EQ
ma
x
Tsai Cheung and
Sweetow 2007
Restricted cochlear lesions in adult animals produce a dynamic reorganization of the
representation or map of the cochlea in the primary auditory cortex
AUDITORY CORTEX
LOW
MID
httpwwwsickkidsoncaotolaryngologyEVOKD-PTasp
18 16 14 12 8
6
18 20 24 26 28
14 8
6 1 mm 12
Pre-Lesion
Post-Lesion
Cat Auditory Cortex
Frequency (kHz)
LOW
M I D
LOW MID
HIGH
Irvine and Rajan (1995)
Research supporting central location
bull Heller and Bergman 1953
bull Andersson et al 1997 Baguley et al 1992
(translabyrinthine surgery)hellip
bull Lockwood and Salvi 1998 Burkard 2001(PET)
bull Kaltenbach 2000 (cochlear nucleus
hyperactivity despite cochlear destruction)
bull Zacharek 2002 (sustained DCN acitivity
following noise damaged cochlear ablation)
bull vascular
bull dementia
bull cardiovascular
diseasehypertension
bull blood disease anemia
bull multiple sclerosis
Some central nervous system pathologies associated with tinnitus
Other factors associated
with tinnitus bull temporomandibular disorders
bull cervical misalignment
bull renal disease Alportrsquos kidney
transplants
bull lyme disease
bull zinc deficiency
bull poor circulation
bull hypothyroid hyperthyroid disorders
Psychological contributions
ndash Cognition maladaptive cognitive strategies ldquoThe reaction is the key to whether a person with tinnitus becomes a tinnitus patientrdquo (Sweetow 1986 2000)
ndash Habituation intolerance results from individualrsquos failure to adapt (Hallam et al 1984 2006)
ndash Attention failure to shift attention away from tinnitus (Hallam and McKenna 2006)
ndash Enhanced tinnitus perception is learned response resulting from ldquonegativerdquo emotional reinforcement involving limbic system and autonomic activation (HallumJastreboff and Hazell 1993 McKenna 2004)hellipde-emphasizes connection with peripheral hearing loss
bull caffeine
bull alcohol
bull nicotine
bull sodium
bull high cholesterol hyperlipidemia hyper and hypothryroidism
bull noise exposure
bull stress
Tinnitus exacerbating factors
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
Modern theories of tinnitus origin
bull Disruption of auditory input (eg hearing loss) and resultant increased gain (activity) within the central auditory system (including the dorsal cochlear nucleus and auditory cortex)
bull Decrease in inhibitory (efferent) function
bull Over-representation of edge-frequencies (cortical plasticity)
bull Dysfunctional gating in basal ganglia
bull Other somatosensory influences (cervical disturbances etc)
bull Increased attention related to reticular activating system involvement
bull Association with fear and threat (limbic system)
Summary of Recent Basal Ganglia Theory
Phantom percepts are represented in the central auditory system
Permission to gate phantom percepts for conscious awareness is controlled by the dorsal striatum
Action to attend reject or accept phantom percepts and form perceptual habits is decided by the ventral striatum
Determination of tinnitus distress severity is mediated through the limbic and paralimbic system-nucleus accumbens-ventral striatum loop
Another ldquogatekeepingrdquo theory
bull The linked network of brain structures involved in emotion
behavior and long-term memorymdashacts as a gatekeeper to
keep the tinnitus signal from reaching the auditory cortex
bull Sensory information enters both the auditory and the limbic
systems through the medial geniculate nucleus (MGN)
bull Before the signal is processed it travels through the thalamic
reticular nucleus (TRN) which evaluates whether or not it
should be passed on
bull There is a significant loss of volume in the medial
prefrontal cortex (mPFC) in people with tinnitus This
structure projects into and activates the TRN If the volume
loss creates a loss of neurons the mPFC and TRN will
malfunction
Rauschecker et al Neuron 2010
Tinnitus is associated with abnormal EEG-
patterns showing enhanced activity in the δ
band and reduced activity in the α band (Weisz
Moratti Meinzer Dohrmann amp Elbert 2005)
MEG data indicating that subjects with
tinnitus
lt 4 years have gamma network predominantly
in the temporal cortex but subjects with
tinnitus of a longer duration show a widely
distributed gamma network into the frontal
and parietal regions (deRidder 2011)
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Correlation between tinnitus
severity and auditory threshold
Tinnitus symptom severity and best
hearing threshold
0
10
20
30
40
50
60
70
80
0 20 40 60 80 100 120
Tinnitus Handicap Inventory Score
Be
st
he
ari
ng
th
res
ho
ld a
t
FR
EQ
ma
x
Tsai Cheung and
Sweetow 2007
Restricted cochlear lesions in adult animals produce a dynamic reorganization of the
representation or map of the cochlea in the primary auditory cortex
AUDITORY CORTEX
LOW
MID
httpwwwsickkidsoncaotolaryngologyEVOKD-PTasp
18 16 14 12 8
6
18 20 24 26 28
14 8
6 1 mm 12
Pre-Lesion
Post-Lesion
Cat Auditory Cortex
Frequency (kHz)
LOW
M I D
LOW MID
HIGH
Irvine and Rajan (1995)
Research supporting central location
bull Heller and Bergman 1953
bull Andersson et al 1997 Baguley et al 1992
(translabyrinthine surgery)hellip
bull Lockwood and Salvi 1998 Burkard 2001(PET)
bull Kaltenbach 2000 (cochlear nucleus
hyperactivity despite cochlear destruction)
bull Zacharek 2002 (sustained DCN acitivity
following noise damaged cochlear ablation)
bull vascular
bull dementia
bull cardiovascular
diseasehypertension
bull blood disease anemia
bull multiple sclerosis
Some central nervous system pathologies associated with tinnitus
Other factors associated
with tinnitus bull temporomandibular disorders
bull cervical misalignment
bull renal disease Alportrsquos kidney
transplants
bull lyme disease
bull zinc deficiency
bull poor circulation
bull hypothyroid hyperthyroid disorders
Psychological contributions
ndash Cognition maladaptive cognitive strategies ldquoThe reaction is the key to whether a person with tinnitus becomes a tinnitus patientrdquo (Sweetow 1986 2000)
ndash Habituation intolerance results from individualrsquos failure to adapt (Hallam et al 1984 2006)
ndash Attention failure to shift attention away from tinnitus (Hallam and McKenna 2006)
ndash Enhanced tinnitus perception is learned response resulting from ldquonegativerdquo emotional reinforcement involving limbic system and autonomic activation (HallumJastreboff and Hazell 1993 McKenna 2004)hellipde-emphasizes connection with peripheral hearing loss
bull caffeine
bull alcohol
bull nicotine
bull sodium
bull high cholesterol hyperlipidemia hyper and hypothryroidism
bull noise exposure
bull stress
Tinnitus exacerbating factors
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
Modern theories of tinnitus origin
bull Disruption of auditory input (eg hearing loss) and resultant increased gain (activity) within the central auditory system (including the dorsal cochlear nucleus and auditory cortex)
bull Decrease in inhibitory (efferent) function
bull Over-representation of edge-frequencies (cortical plasticity)
bull Dysfunctional gating in basal ganglia
bull Other somatosensory influences (cervical disturbances etc)
bull Increased attention related to reticular activating system involvement
bull Association with fear and threat (limbic system)
Summary of Recent Basal Ganglia Theory
Phantom percepts are represented in the central auditory system
Permission to gate phantom percepts for conscious awareness is controlled by the dorsal striatum
Action to attend reject or accept phantom percepts and form perceptual habits is decided by the ventral striatum
Determination of tinnitus distress severity is mediated through the limbic and paralimbic system-nucleus accumbens-ventral striatum loop
Another ldquogatekeepingrdquo theory
bull The linked network of brain structures involved in emotion
behavior and long-term memorymdashacts as a gatekeeper to
keep the tinnitus signal from reaching the auditory cortex
bull Sensory information enters both the auditory and the limbic
systems through the medial geniculate nucleus (MGN)
bull Before the signal is processed it travels through the thalamic
reticular nucleus (TRN) which evaluates whether or not it
should be passed on
bull There is a significant loss of volume in the medial
prefrontal cortex (mPFC) in people with tinnitus This
structure projects into and activates the TRN If the volume
loss creates a loss of neurons the mPFC and TRN will
malfunction
Rauschecker et al Neuron 2010
Tinnitus is associated with abnormal EEG-
patterns showing enhanced activity in the δ
band and reduced activity in the α band (Weisz
Moratti Meinzer Dohrmann amp Elbert 2005)
MEG data indicating that subjects with
tinnitus
lt 4 years have gamma network predominantly
in the temporal cortex but subjects with
tinnitus of a longer duration show a widely
distributed gamma network into the frontal
and parietal regions (deRidder 2011)
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Restricted cochlear lesions in adult animals produce a dynamic reorganization of the
representation or map of the cochlea in the primary auditory cortex
AUDITORY CORTEX
LOW
MID
httpwwwsickkidsoncaotolaryngologyEVOKD-PTasp
18 16 14 12 8
6
18 20 24 26 28
14 8
6 1 mm 12
Pre-Lesion
Post-Lesion
Cat Auditory Cortex
Frequency (kHz)
LOW
M I D
LOW MID
HIGH
Irvine and Rajan (1995)
Research supporting central location
bull Heller and Bergman 1953
bull Andersson et al 1997 Baguley et al 1992
(translabyrinthine surgery)hellip
bull Lockwood and Salvi 1998 Burkard 2001(PET)
bull Kaltenbach 2000 (cochlear nucleus
hyperactivity despite cochlear destruction)
bull Zacharek 2002 (sustained DCN acitivity
following noise damaged cochlear ablation)
bull vascular
bull dementia
bull cardiovascular
diseasehypertension
bull blood disease anemia
bull multiple sclerosis
Some central nervous system pathologies associated with tinnitus
Other factors associated
with tinnitus bull temporomandibular disorders
bull cervical misalignment
bull renal disease Alportrsquos kidney
transplants
bull lyme disease
bull zinc deficiency
bull poor circulation
bull hypothyroid hyperthyroid disorders
Psychological contributions
ndash Cognition maladaptive cognitive strategies ldquoThe reaction is the key to whether a person with tinnitus becomes a tinnitus patientrdquo (Sweetow 1986 2000)
ndash Habituation intolerance results from individualrsquos failure to adapt (Hallam et al 1984 2006)
ndash Attention failure to shift attention away from tinnitus (Hallam and McKenna 2006)
ndash Enhanced tinnitus perception is learned response resulting from ldquonegativerdquo emotional reinforcement involving limbic system and autonomic activation (HallumJastreboff and Hazell 1993 McKenna 2004)hellipde-emphasizes connection with peripheral hearing loss
bull caffeine
bull alcohol
bull nicotine
bull sodium
bull high cholesterol hyperlipidemia hyper and hypothryroidism
bull noise exposure
bull stress
Tinnitus exacerbating factors
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
Modern theories of tinnitus origin
bull Disruption of auditory input (eg hearing loss) and resultant increased gain (activity) within the central auditory system (including the dorsal cochlear nucleus and auditory cortex)
bull Decrease in inhibitory (efferent) function
bull Over-representation of edge-frequencies (cortical plasticity)
bull Dysfunctional gating in basal ganglia
bull Other somatosensory influences (cervical disturbances etc)
bull Increased attention related to reticular activating system involvement
bull Association with fear and threat (limbic system)
Summary of Recent Basal Ganglia Theory
Phantom percepts are represented in the central auditory system
Permission to gate phantom percepts for conscious awareness is controlled by the dorsal striatum
Action to attend reject or accept phantom percepts and form perceptual habits is decided by the ventral striatum
Determination of tinnitus distress severity is mediated through the limbic and paralimbic system-nucleus accumbens-ventral striatum loop
Another ldquogatekeepingrdquo theory
bull The linked network of brain structures involved in emotion
behavior and long-term memorymdashacts as a gatekeeper to
keep the tinnitus signal from reaching the auditory cortex
bull Sensory information enters both the auditory and the limbic
systems through the medial geniculate nucleus (MGN)
bull Before the signal is processed it travels through the thalamic
reticular nucleus (TRN) which evaluates whether or not it
should be passed on
bull There is a significant loss of volume in the medial
prefrontal cortex (mPFC) in people with tinnitus This
structure projects into and activates the TRN If the volume
loss creates a loss of neurons the mPFC and TRN will
malfunction
Rauschecker et al Neuron 2010
Tinnitus is associated with abnormal EEG-
patterns showing enhanced activity in the δ
band and reduced activity in the α band (Weisz
Moratti Meinzer Dohrmann amp Elbert 2005)
MEG data indicating that subjects with
tinnitus
lt 4 years have gamma network predominantly
in the temporal cortex but subjects with
tinnitus of a longer duration show a widely
distributed gamma network into the frontal
and parietal regions (deRidder 2011)
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
AUDITORY CORTEX
LOW
MID
httpwwwsickkidsoncaotolaryngologyEVOKD-PTasp
18 16 14 12 8
6
18 20 24 26 28
14 8
6 1 mm 12
Pre-Lesion
Post-Lesion
Cat Auditory Cortex
Frequency (kHz)
LOW
M I D
LOW MID
HIGH
Irvine and Rajan (1995)
Research supporting central location
bull Heller and Bergman 1953
bull Andersson et al 1997 Baguley et al 1992
(translabyrinthine surgery)hellip
bull Lockwood and Salvi 1998 Burkard 2001(PET)
bull Kaltenbach 2000 (cochlear nucleus
hyperactivity despite cochlear destruction)
bull Zacharek 2002 (sustained DCN acitivity
following noise damaged cochlear ablation)
bull vascular
bull dementia
bull cardiovascular
diseasehypertension
bull blood disease anemia
bull multiple sclerosis
Some central nervous system pathologies associated with tinnitus
Other factors associated
with tinnitus bull temporomandibular disorders
bull cervical misalignment
bull renal disease Alportrsquos kidney
transplants
bull lyme disease
bull zinc deficiency
bull poor circulation
bull hypothyroid hyperthyroid disorders
Psychological contributions
ndash Cognition maladaptive cognitive strategies ldquoThe reaction is the key to whether a person with tinnitus becomes a tinnitus patientrdquo (Sweetow 1986 2000)
ndash Habituation intolerance results from individualrsquos failure to adapt (Hallam et al 1984 2006)
ndash Attention failure to shift attention away from tinnitus (Hallam and McKenna 2006)
ndash Enhanced tinnitus perception is learned response resulting from ldquonegativerdquo emotional reinforcement involving limbic system and autonomic activation (HallumJastreboff and Hazell 1993 McKenna 2004)hellipde-emphasizes connection with peripheral hearing loss
bull caffeine
bull alcohol
bull nicotine
bull sodium
bull high cholesterol hyperlipidemia hyper and hypothryroidism
bull noise exposure
bull stress
Tinnitus exacerbating factors
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
Modern theories of tinnitus origin
bull Disruption of auditory input (eg hearing loss) and resultant increased gain (activity) within the central auditory system (including the dorsal cochlear nucleus and auditory cortex)
bull Decrease in inhibitory (efferent) function
bull Over-representation of edge-frequencies (cortical plasticity)
bull Dysfunctional gating in basal ganglia
bull Other somatosensory influences (cervical disturbances etc)
bull Increased attention related to reticular activating system involvement
bull Association with fear and threat (limbic system)
Summary of Recent Basal Ganglia Theory
Phantom percepts are represented in the central auditory system
Permission to gate phantom percepts for conscious awareness is controlled by the dorsal striatum
Action to attend reject or accept phantom percepts and form perceptual habits is decided by the ventral striatum
Determination of tinnitus distress severity is mediated through the limbic and paralimbic system-nucleus accumbens-ventral striatum loop
Another ldquogatekeepingrdquo theory
bull The linked network of brain structures involved in emotion
behavior and long-term memorymdashacts as a gatekeeper to
keep the tinnitus signal from reaching the auditory cortex
bull Sensory information enters both the auditory and the limbic
systems through the medial geniculate nucleus (MGN)
bull Before the signal is processed it travels through the thalamic
reticular nucleus (TRN) which evaluates whether or not it
should be passed on
bull There is a significant loss of volume in the medial
prefrontal cortex (mPFC) in people with tinnitus This
structure projects into and activates the TRN If the volume
loss creates a loss of neurons the mPFC and TRN will
malfunction
Rauschecker et al Neuron 2010
Tinnitus is associated with abnormal EEG-
patterns showing enhanced activity in the δ
band and reduced activity in the α band (Weisz
Moratti Meinzer Dohrmann amp Elbert 2005)
MEG data indicating that subjects with
tinnitus
lt 4 years have gamma network predominantly
in the temporal cortex but subjects with
tinnitus of a longer duration show a widely
distributed gamma network into the frontal
and parietal regions (deRidder 2011)
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
18 16 14 12 8
6
18 20 24 26 28
14 8
6 1 mm 12
Pre-Lesion
Post-Lesion
Cat Auditory Cortex
Frequency (kHz)
LOW
M I D
LOW MID
HIGH
Irvine and Rajan (1995)
Research supporting central location
bull Heller and Bergman 1953
bull Andersson et al 1997 Baguley et al 1992
(translabyrinthine surgery)hellip
bull Lockwood and Salvi 1998 Burkard 2001(PET)
bull Kaltenbach 2000 (cochlear nucleus
hyperactivity despite cochlear destruction)
bull Zacharek 2002 (sustained DCN acitivity
following noise damaged cochlear ablation)
bull vascular
bull dementia
bull cardiovascular
diseasehypertension
bull blood disease anemia
bull multiple sclerosis
Some central nervous system pathologies associated with tinnitus
Other factors associated
with tinnitus bull temporomandibular disorders
bull cervical misalignment
bull renal disease Alportrsquos kidney
transplants
bull lyme disease
bull zinc deficiency
bull poor circulation
bull hypothyroid hyperthyroid disorders
Psychological contributions
ndash Cognition maladaptive cognitive strategies ldquoThe reaction is the key to whether a person with tinnitus becomes a tinnitus patientrdquo (Sweetow 1986 2000)
ndash Habituation intolerance results from individualrsquos failure to adapt (Hallam et al 1984 2006)
ndash Attention failure to shift attention away from tinnitus (Hallam and McKenna 2006)
ndash Enhanced tinnitus perception is learned response resulting from ldquonegativerdquo emotional reinforcement involving limbic system and autonomic activation (HallumJastreboff and Hazell 1993 McKenna 2004)hellipde-emphasizes connection with peripheral hearing loss
bull caffeine
bull alcohol
bull nicotine
bull sodium
bull high cholesterol hyperlipidemia hyper and hypothryroidism
bull noise exposure
bull stress
Tinnitus exacerbating factors
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
Modern theories of tinnitus origin
bull Disruption of auditory input (eg hearing loss) and resultant increased gain (activity) within the central auditory system (including the dorsal cochlear nucleus and auditory cortex)
bull Decrease in inhibitory (efferent) function
bull Over-representation of edge-frequencies (cortical plasticity)
bull Dysfunctional gating in basal ganglia
bull Other somatosensory influences (cervical disturbances etc)
bull Increased attention related to reticular activating system involvement
bull Association with fear and threat (limbic system)
Summary of Recent Basal Ganglia Theory
Phantom percepts are represented in the central auditory system
Permission to gate phantom percepts for conscious awareness is controlled by the dorsal striatum
Action to attend reject or accept phantom percepts and form perceptual habits is decided by the ventral striatum
Determination of tinnitus distress severity is mediated through the limbic and paralimbic system-nucleus accumbens-ventral striatum loop
Another ldquogatekeepingrdquo theory
bull The linked network of brain structures involved in emotion
behavior and long-term memorymdashacts as a gatekeeper to
keep the tinnitus signal from reaching the auditory cortex
bull Sensory information enters both the auditory and the limbic
systems through the medial geniculate nucleus (MGN)
bull Before the signal is processed it travels through the thalamic
reticular nucleus (TRN) which evaluates whether or not it
should be passed on
bull There is a significant loss of volume in the medial
prefrontal cortex (mPFC) in people with tinnitus This
structure projects into and activates the TRN If the volume
loss creates a loss of neurons the mPFC and TRN will
malfunction
Rauschecker et al Neuron 2010
Tinnitus is associated with abnormal EEG-
patterns showing enhanced activity in the δ
band and reduced activity in the α band (Weisz
Moratti Meinzer Dohrmann amp Elbert 2005)
MEG data indicating that subjects with
tinnitus
lt 4 years have gamma network predominantly
in the temporal cortex but subjects with
tinnitus of a longer duration show a widely
distributed gamma network into the frontal
and parietal regions (deRidder 2011)
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Research supporting central location
bull Heller and Bergman 1953
bull Andersson et al 1997 Baguley et al 1992
(translabyrinthine surgery)hellip
bull Lockwood and Salvi 1998 Burkard 2001(PET)
bull Kaltenbach 2000 (cochlear nucleus
hyperactivity despite cochlear destruction)
bull Zacharek 2002 (sustained DCN acitivity
following noise damaged cochlear ablation)
bull vascular
bull dementia
bull cardiovascular
diseasehypertension
bull blood disease anemia
bull multiple sclerosis
Some central nervous system pathologies associated with tinnitus
Other factors associated
with tinnitus bull temporomandibular disorders
bull cervical misalignment
bull renal disease Alportrsquos kidney
transplants
bull lyme disease
bull zinc deficiency
bull poor circulation
bull hypothyroid hyperthyroid disorders
Psychological contributions
ndash Cognition maladaptive cognitive strategies ldquoThe reaction is the key to whether a person with tinnitus becomes a tinnitus patientrdquo (Sweetow 1986 2000)
ndash Habituation intolerance results from individualrsquos failure to adapt (Hallam et al 1984 2006)
ndash Attention failure to shift attention away from tinnitus (Hallam and McKenna 2006)
ndash Enhanced tinnitus perception is learned response resulting from ldquonegativerdquo emotional reinforcement involving limbic system and autonomic activation (HallumJastreboff and Hazell 1993 McKenna 2004)hellipde-emphasizes connection with peripheral hearing loss
bull caffeine
bull alcohol
bull nicotine
bull sodium
bull high cholesterol hyperlipidemia hyper and hypothryroidism
bull noise exposure
bull stress
Tinnitus exacerbating factors
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
Modern theories of tinnitus origin
bull Disruption of auditory input (eg hearing loss) and resultant increased gain (activity) within the central auditory system (including the dorsal cochlear nucleus and auditory cortex)
bull Decrease in inhibitory (efferent) function
bull Over-representation of edge-frequencies (cortical plasticity)
bull Dysfunctional gating in basal ganglia
bull Other somatosensory influences (cervical disturbances etc)
bull Increased attention related to reticular activating system involvement
bull Association with fear and threat (limbic system)
Summary of Recent Basal Ganglia Theory
Phantom percepts are represented in the central auditory system
Permission to gate phantom percepts for conscious awareness is controlled by the dorsal striatum
Action to attend reject or accept phantom percepts and form perceptual habits is decided by the ventral striatum
Determination of tinnitus distress severity is mediated through the limbic and paralimbic system-nucleus accumbens-ventral striatum loop
Another ldquogatekeepingrdquo theory
bull The linked network of brain structures involved in emotion
behavior and long-term memorymdashacts as a gatekeeper to
keep the tinnitus signal from reaching the auditory cortex
bull Sensory information enters both the auditory and the limbic
systems through the medial geniculate nucleus (MGN)
bull Before the signal is processed it travels through the thalamic
reticular nucleus (TRN) which evaluates whether or not it
should be passed on
bull There is a significant loss of volume in the medial
prefrontal cortex (mPFC) in people with tinnitus This
structure projects into and activates the TRN If the volume
loss creates a loss of neurons the mPFC and TRN will
malfunction
Rauschecker et al Neuron 2010
Tinnitus is associated with abnormal EEG-
patterns showing enhanced activity in the δ
band and reduced activity in the α band (Weisz
Moratti Meinzer Dohrmann amp Elbert 2005)
MEG data indicating that subjects with
tinnitus
lt 4 years have gamma network predominantly
in the temporal cortex but subjects with
tinnitus of a longer duration show a widely
distributed gamma network into the frontal
and parietal regions (deRidder 2011)
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
bull vascular
bull dementia
bull cardiovascular
diseasehypertension
bull blood disease anemia
bull multiple sclerosis
Some central nervous system pathologies associated with tinnitus
Other factors associated
with tinnitus bull temporomandibular disorders
bull cervical misalignment
bull renal disease Alportrsquos kidney
transplants
bull lyme disease
bull zinc deficiency
bull poor circulation
bull hypothyroid hyperthyroid disorders
Psychological contributions
ndash Cognition maladaptive cognitive strategies ldquoThe reaction is the key to whether a person with tinnitus becomes a tinnitus patientrdquo (Sweetow 1986 2000)
ndash Habituation intolerance results from individualrsquos failure to adapt (Hallam et al 1984 2006)
ndash Attention failure to shift attention away from tinnitus (Hallam and McKenna 2006)
ndash Enhanced tinnitus perception is learned response resulting from ldquonegativerdquo emotional reinforcement involving limbic system and autonomic activation (HallumJastreboff and Hazell 1993 McKenna 2004)hellipde-emphasizes connection with peripheral hearing loss
bull caffeine
bull alcohol
bull nicotine
bull sodium
bull high cholesterol hyperlipidemia hyper and hypothryroidism
bull noise exposure
bull stress
Tinnitus exacerbating factors
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
Modern theories of tinnitus origin
bull Disruption of auditory input (eg hearing loss) and resultant increased gain (activity) within the central auditory system (including the dorsal cochlear nucleus and auditory cortex)
bull Decrease in inhibitory (efferent) function
bull Over-representation of edge-frequencies (cortical plasticity)
bull Dysfunctional gating in basal ganglia
bull Other somatosensory influences (cervical disturbances etc)
bull Increased attention related to reticular activating system involvement
bull Association with fear and threat (limbic system)
Summary of Recent Basal Ganglia Theory
Phantom percepts are represented in the central auditory system
Permission to gate phantom percepts for conscious awareness is controlled by the dorsal striatum
Action to attend reject or accept phantom percepts and form perceptual habits is decided by the ventral striatum
Determination of tinnitus distress severity is mediated through the limbic and paralimbic system-nucleus accumbens-ventral striatum loop
Another ldquogatekeepingrdquo theory
bull The linked network of brain structures involved in emotion
behavior and long-term memorymdashacts as a gatekeeper to
keep the tinnitus signal from reaching the auditory cortex
bull Sensory information enters both the auditory and the limbic
systems through the medial geniculate nucleus (MGN)
bull Before the signal is processed it travels through the thalamic
reticular nucleus (TRN) which evaluates whether or not it
should be passed on
bull There is a significant loss of volume in the medial
prefrontal cortex (mPFC) in people with tinnitus This
structure projects into and activates the TRN If the volume
loss creates a loss of neurons the mPFC and TRN will
malfunction
Rauschecker et al Neuron 2010
Tinnitus is associated with abnormal EEG-
patterns showing enhanced activity in the δ
band and reduced activity in the α band (Weisz
Moratti Meinzer Dohrmann amp Elbert 2005)
MEG data indicating that subjects with
tinnitus
lt 4 years have gamma network predominantly
in the temporal cortex but subjects with
tinnitus of a longer duration show a widely
distributed gamma network into the frontal
and parietal regions (deRidder 2011)
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Other factors associated
with tinnitus bull temporomandibular disorders
bull cervical misalignment
bull renal disease Alportrsquos kidney
transplants
bull lyme disease
bull zinc deficiency
bull poor circulation
bull hypothyroid hyperthyroid disorders
Psychological contributions
ndash Cognition maladaptive cognitive strategies ldquoThe reaction is the key to whether a person with tinnitus becomes a tinnitus patientrdquo (Sweetow 1986 2000)
ndash Habituation intolerance results from individualrsquos failure to adapt (Hallam et al 1984 2006)
ndash Attention failure to shift attention away from tinnitus (Hallam and McKenna 2006)
ndash Enhanced tinnitus perception is learned response resulting from ldquonegativerdquo emotional reinforcement involving limbic system and autonomic activation (HallumJastreboff and Hazell 1993 McKenna 2004)hellipde-emphasizes connection with peripheral hearing loss
bull caffeine
bull alcohol
bull nicotine
bull sodium
bull high cholesterol hyperlipidemia hyper and hypothryroidism
bull noise exposure
bull stress
Tinnitus exacerbating factors
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
Modern theories of tinnitus origin
bull Disruption of auditory input (eg hearing loss) and resultant increased gain (activity) within the central auditory system (including the dorsal cochlear nucleus and auditory cortex)
bull Decrease in inhibitory (efferent) function
bull Over-representation of edge-frequencies (cortical plasticity)
bull Dysfunctional gating in basal ganglia
bull Other somatosensory influences (cervical disturbances etc)
bull Increased attention related to reticular activating system involvement
bull Association with fear and threat (limbic system)
Summary of Recent Basal Ganglia Theory
Phantom percepts are represented in the central auditory system
Permission to gate phantom percepts for conscious awareness is controlled by the dorsal striatum
Action to attend reject or accept phantom percepts and form perceptual habits is decided by the ventral striatum
Determination of tinnitus distress severity is mediated through the limbic and paralimbic system-nucleus accumbens-ventral striatum loop
Another ldquogatekeepingrdquo theory
bull The linked network of brain structures involved in emotion
behavior and long-term memorymdashacts as a gatekeeper to
keep the tinnitus signal from reaching the auditory cortex
bull Sensory information enters both the auditory and the limbic
systems through the medial geniculate nucleus (MGN)
bull Before the signal is processed it travels through the thalamic
reticular nucleus (TRN) which evaluates whether or not it
should be passed on
bull There is a significant loss of volume in the medial
prefrontal cortex (mPFC) in people with tinnitus This
structure projects into and activates the TRN If the volume
loss creates a loss of neurons the mPFC and TRN will
malfunction
Rauschecker et al Neuron 2010
Tinnitus is associated with abnormal EEG-
patterns showing enhanced activity in the δ
band and reduced activity in the α band (Weisz
Moratti Meinzer Dohrmann amp Elbert 2005)
MEG data indicating that subjects with
tinnitus
lt 4 years have gamma network predominantly
in the temporal cortex but subjects with
tinnitus of a longer duration show a widely
distributed gamma network into the frontal
and parietal regions (deRidder 2011)
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Psychological contributions
ndash Cognition maladaptive cognitive strategies ldquoThe reaction is the key to whether a person with tinnitus becomes a tinnitus patientrdquo (Sweetow 1986 2000)
ndash Habituation intolerance results from individualrsquos failure to adapt (Hallam et al 1984 2006)
ndash Attention failure to shift attention away from tinnitus (Hallam and McKenna 2006)
ndash Enhanced tinnitus perception is learned response resulting from ldquonegativerdquo emotional reinforcement involving limbic system and autonomic activation (HallumJastreboff and Hazell 1993 McKenna 2004)hellipde-emphasizes connection with peripheral hearing loss
bull caffeine
bull alcohol
bull nicotine
bull sodium
bull high cholesterol hyperlipidemia hyper and hypothryroidism
bull noise exposure
bull stress
Tinnitus exacerbating factors
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
Modern theories of tinnitus origin
bull Disruption of auditory input (eg hearing loss) and resultant increased gain (activity) within the central auditory system (including the dorsal cochlear nucleus and auditory cortex)
bull Decrease in inhibitory (efferent) function
bull Over-representation of edge-frequencies (cortical plasticity)
bull Dysfunctional gating in basal ganglia
bull Other somatosensory influences (cervical disturbances etc)
bull Increased attention related to reticular activating system involvement
bull Association with fear and threat (limbic system)
Summary of Recent Basal Ganglia Theory
Phantom percepts are represented in the central auditory system
Permission to gate phantom percepts for conscious awareness is controlled by the dorsal striatum
Action to attend reject or accept phantom percepts and form perceptual habits is decided by the ventral striatum
Determination of tinnitus distress severity is mediated through the limbic and paralimbic system-nucleus accumbens-ventral striatum loop
Another ldquogatekeepingrdquo theory
bull The linked network of brain structures involved in emotion
behavior and long-term memorymdashacts as a gatekeeper to
keep the tinnitus signal from reaching the auditory cortex
bull Sensory information enters both the auditory and the limbic
systems through the medial geniculate nucleus (MGN)
bull Before the signal is processed it travels through the thalamic
reticular nucleus (TRN) which evaluates whether or not it
should be passed on
bull There is a significant loss of volume in the medial
prefrontal cortex (mPFC) in people with tinnitus This
structure projects into and activates the TRN If the volume
loss creates a loss of neurons the mPFC and TRN will
malfunction
Rauschecker et al Neuron 2010
Tinnitus is associated with abnormal EEG-
patterns showing enhanced activity in the δ
band and reduced activity in the α band (Weisz
Moratti Meinzer Dohrmann amp Elbert 2005)
MEG data indicating that subjects with
tinnitus
lt 4 years have gamma network predominantly
in the temporal cortex but subjects with
tinnitus of a longer duration show a widely
distributed gamma network into the frontal
and parietal regions (deRidder 2011)
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
bull caffeine
bull alcohol
bull nicotine
bull sodium
bull high cholesterol hyperlipidemia hyper and hypothryroidism
bull noise exposure
bull stress
Tinnitus exacerbating factors
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
Modern theories of tinnitus origin
bull Disruption of auditory input (eg hearing loss) and resultant increased gain (activity) within the central auditory system (including the dorsal cochlear nucleus and auditory cortex)
bull Decrease in inhibitory (efferent) function
bull Over-representation of edge-frequencies (cortical plasticity)
bull Dysfunctional gating in basal ganglia
bull Other somatosensory influences (cervical disturbances etc)
bull Increased attention related to reticular activating system involvement
bull Association with fear and threat (limbic system)
Summary of Recent Basal Ganglia Theory
Phantom percepts are represented in the central auditory system
Permission to gate phantom percepts for conscious awareness is controlled by the dorsal striatum
Action to attend reject or accept phantom percepts and form perceptual habits is decided by the ventral striatum
Determination of tinnitus distress severity is mediated through the limbic and paralimbic system-nucleus accumbens-ventral striatum loop
Another ldquogatekeepingrdquo theory
bull The linked network of brain structures involved in emotion
behavior and long-term memorymdashacts as a gatekeeper to
keep the tinnitus signal from reaching the auditory cortex
bull Sensory information enters both the auditory and the limbic
systems through the medial geniculate nucleus (MGN)
bull Before the signal is processed it travels through the thalamic
reticular nucleus (TRN) which evaluates whether or not it
should be passed on
bull There is a significant loss of volume in the medial
prefrontal cortex (mPFC) in people with tinnitus This
structure projects into and activates the TRN If the volume
loss creates a loss of neurons the mPFC and TRN will
malfunction
Rauschecker et al Neuron 2010
Tinnitus is associated with abnormal EEG-
patterns showing enhanced activity in the δ
band and reduced activity in the α band (Weisz
Moratti Meinzer Dohrmann amp Elbert 2005)
MEG data indicating that subjects with
tinnitus
lt 4 years have gamma network predominantly
in the temporal cortex but subjects with
tinnitus of a longer duration show a widely
distributed gamma network into the frontal
and parietal regions (deRidder 2011)
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
Modern theories of tinnitus origin
bull Disruption of auditory input (eg hearing loss) and resultant increased gain (activity) within the central auditory system (including the dorsal cochlear nucleus and auditory cortex)
bull Decrease in inhibitory (efferent) function
bull Over-representation of edge-frequencies (cortical plasticity)
bull Dysfunctional gating in basal ganglia
bull Other somatosensory influences (cervical disturbances etc)
bull Increased attention related to reticular activating system involvement
bull Association with fear and threat (limbic system)
Summary of Recent Basal Ganglia Theory
Phantom percepts are represented in the central auditory system
Permission to gate phantom percepts for conscious awareness is controlled by the dorsal striatum
Action to attend reject or accept phantom percepts and form perceptual habits is decided by the ventral striatum
Determination of tinnitus distress severity is mediated through the limbic and paralimbic system-nucleus accumbens-ventral striatum loop
Another ldquogatekeepingrdquo theory
bull The linked network of brain structures involved in emotion
behavior and long-term memorymdashacts as a gatekeeper to
keep the tinnitus signal from reaching the auditory cortex
bull Sensory information enters both the auditory and the limbic
systems through the medial geniculate nucleus (MGN)
bull Before the signal is processed it travels through the thalamic
reticular nucleus (TRN) which evaluates whether or not it
should be passed on
bull There is a significant loss of volume in the medial
prefrontal cortex (mPFC) in people with tinnitus This
structure projects into and activates the TRN If the volume
loss creates a loss of neurons the mPFC and TRN will
malfunction
Rauschecker et al Neuron 2010
Tinnitus is associated with abnormal EEG-
patterns showing enhanced activity in the δ
band and reduced activity in the α band (Weisz
Moratti Meinzer Dohrmann amp Elbert 2005)
MEG data indicating that subjects with
tinnitus
lt 4 years have gamma network predominantly
in the temporal cortex but subjects with
tinnitus of a longer duration show a widely
distributed gamma network into the frontal
and parietal regions (deRidder 2011)
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Modern theories of tinnitus origin
bull Disruption of auditory input (eg hearing loss) and resultant increased gain (activity) within the central auditory system (including the dorsal cochlear nucleus and auditory cortex)
bull Decrease in inhibitory (efferent) function
bull Over-representation of edge-frequencies (cortical plasticity)
bull Dysfunctional gating in basal ganglia
bull Other somatosensory influences (cervical disturbances etc)
bull Increased attention related to reticular activating system involvement
bull Association with fear and threat (limbic system)
Summary of Recent Basal Ganglia Theory
Phantom percepts are represented in the central auditory system
Permission to gate phantom percepts for conscious awareness is controlled by the dorsal striatum
Action to attend reject or accept phantom percepts and form perceptual habits is decided by the ventral striatum
Determination of tinnitus distress severity is mediated through the limbic and paralimbic system-nucleus accumbens-ventral striatum loop
Another ldquogatekeepingrdquo theory
bull The linked network of brain structures involved in emotion
behavior and long-term memorymdashacts as a gatekeeper to
keep the tinnitus signal from reaching the auditory cortex
bull Sensory information enters both the auditory and the limbic
systems through the medial geniculate nucleus (MGN)
bull Before the signal is processed it travels through the thalamic
reticular nucleus (TRN) which evaluates whether or not it
should be passed on
bull There is a significant loss of volume in the medial
prefrontal cortex (mPFC) in people with tinnitus This
structure projects into and activates the TRN If the volume
loss creates a loss of neurons the mPFC and TRN will
malfunction
Rauschecker et al Neuron 2010
Tinnitus is associated with abnormal EEG-
patterns showing enhanced activity in the δ
band and reduced activity in the α band (Weisz
Moratti Meinzer Dohrmann amp Elbert 2005)
MEG data indicating that subjects with
tinnitus
lt 4 years have gamma network predominantly
in the temporal cortex but subjects with
tinnitus of a longer duration show a widely
distributed gamma network into the frontal
and parietal regions (deRidder 2011)
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Summary of Recent Basal Ganglia Theory
Phantom percepts are represented in the central auditory system
Permission to gate phantom percepts for conscious awareness is controlled by the dorsal striatum
Action to attend reject or accept phantom percepts and form perceptual habits is decided by the ventral striatum
Determination of tinnitus distress severity is mediated through the limbic and paralimbic system-nucleus accumbens-ventral striatum loop
Another ldquogatekeepingrdquo theory
bull The linked network of brain structures involved in emotion
behavior and long-term memorymdashacts as a gatekeeper to
keep the tinnitus signal from reaching the auditory cortex
bull Sensory information enters both the auditory and the limbic
systems through the medial geniculate nucleus (MGN)
bull Before the signal is processed it travels through the thalamic
reticular nucleus (TRN) which evaluates whether or not it
should be passed on
bull There is a significant loss of volume in the medial
prefrontal cortex (mPFC) in people with tinnitus This
structure projects into and activates the TRN If the volume
loss creates a loss of neurons the mPFC and TRN will
malfunction
Rauschecker et al Neuron 2010
Tinnitus is associated with abnormal EEG-
patterns showing enhanced activity in the δ
band and reduced activity in the α band (Weisz
Moratti Meinzer Dohrmann amp Elbert 2005)
MEG data indicating that subjects with
tinnitus
lt 4 years have gamma network predominantly
in the temporal cortex but subjects with
tinnitus of a longer duration show a widely
distributed gamma network into the frontal
and parietal regions (deRidder 2011)
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Another ldquogatekeepingrdquo theory
bull The linked network of brain structures involved in emotion
behavior and long-term memorymdashacts as a gatekeeper to
keep the tinnitus signal from reaching the auditory cortex
bull Sensory information enters both the auditory and the limbic
systems through the medial geniculate nucleus (MGN)
bull Before the signal is processed it travels through the thalamic
reticular nucleus (TRN) which evaluates whether or not it
should be passed on
bull There is a significant loss of volume in the medial
prefrontal cortex (mPFC) in people with tinnitus This
structure projects into and activates the TRN If the volume
loss creates a loss of neurons the mPFC and TRN will
malfunction
Rauschecker et al Neuron 2010
Tinnitus is associated with abnormal EEG-
patterns showing enhanced activity in the δ
band and reduced activity in the α band (Weisz
Moratti Meinzer Dohrmann amp Elbert 2005)
MEG data indicating that subjects with
tinnitus
lt 4 years have gamma network predominantly
in the temporal cortex but subjects with
tinnitus of a longer duration show a widely
distributed gamma network into the frontal
and parietal regions (deRidder 2011)
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Tinnitus is associated with abnormal EEG-
patterns showing enhanced activity in the δ
band and reduced activity in the α band (Weisz
Moratti Meinzer Dohrmann amp Elbert 2005)
MEG data indicating that subjects with
tinnitus
lt 4 years have gamma network predominantly
in the temporal cortex but subjects with
tinnitus of a longer duration show a widely
distributed gamma network into the frontal
and parietal regions (deRidder 2011)
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Perception amp Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Enabler (Impaired cochlea is one example of a factor creating neural instructions for tinnitus percepts)
Emotional Associations
Limbic System Frontal
lobe (rostral anterior
cingulate cortex)
Annoyancee
Abnormal
gating
Revised habituation model
Dashed lines represent neutral interpretation of tinnitus percept
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Questions requiring more clarification
bull Why donrsquot all hearing impaired individuals have tinnitus for
example why do only 20-40 of persons with noise
induced hearing loss have it is it blocked sub-cortically
bull Based on discordant damage theory shouldnrsquot the largest
group of tinnitus patients have a ~50 dB loss
bull Do the 30 of tinnitus patients who have normal hearing
all have undocumented OHC damage Why donrsquot OAEs
show this
bull Why canrsquot we accurately predict laterality percept
bull Why is tinnitus merely a minor distraction for 80
bull Why canrsquot we ldquocounsel awayrdquo abnormal autonomic nervous
system activation for more patients
bull Why do so many patients report intermittent or fluctuating
tinnitus
bull Why do some people have ldquoreactiverdquo tinnitus
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Three aspects of tinnitus that
should be addressed
bull auditory
bull attentional
bull emotional
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
bull Otologic
bull Medical
bull Audiologic
bull Diet
bull Exercise
bull Emotional Pattern
bull Sleep
bull Previous Treatments
Tinnitus Questionnaire
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Assessment Inventories
bull Tinnitus Severity Scale - Sweetow and Levy
bull Tinnitus Handicap Inventory - Newman et al
bull Tinnitus Handicap Questionnaire - Kuk et al
bull Tinnitus Effects Questionnaire - Hallam et al
bull Tinnitus Reaction Questionnaire - Wilson et al
bull Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
bull Tinnitus Functional Index ndash Miekle et al
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Tinnitus Handicap Inventory (THI) - Newman et al 1998
bull 25 items (yes - 4 sometimes - 2 no - 0)
ndash functional
ndash emotional
ndash catastrophic
bull THI = 0-16 No handicap
bull THI = 18-36 Mild handicap
bull THI = 38-56 Moderate handicap
bull THI = 58-100 Severe handicap
bull 20 point difference = significant change
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Tinnitus Functional Index (TFI)
bull 25 items designed to address 8 important domains of negative tinnitus impact ndash intrusiveness reduced sense of control cognitive
interference sleep disturbance auditory difficulties attributed to tinnitus interference with relaxation quality of life reduced and emotional distress
bull Each of the 8 subscales consist of 3 items except for the quality of life subscale which consist of 4 items
bull All items are scored using a percentage score or a 0-10 scale giving a maximum possible score of 250 (which is then divided by 25 and multiplied by 10 for a max score of 100)
bull The TFI is useful for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
bull time
bull behaviors affected
bull attitudes and thoughts
bull what affects the tinnitus
Defining the tinnitus problem
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Tinnitus triggers
bull Physical (viral medication hearing loss (imbalance between excitatory and inhibitory neurons) neurotoxicity from noise somatic influences)
bull psychological
bull retirement syndrome
bull stress related
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Give the patient a chance to vent
But only for a while
hellipAnd less time each visit
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Potentially useful diagnostic procedures
bull audiogram
bull assessment (severity) scales
bull psychological profiles
bull tinnitus matching (do loudness match first)
bull loudness discomfort levels
bull minimum masking levels
bull OAEs
bull ultra high frequency testing
bull immittancereflexesdecay
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Tinnitus matching
bull usually less than 6 dB SL
bull may be more appropriate
to convert to sones
bull 82 match above
3KHz
bull 14 match above
9KHz
Loudness Pitch
Maskability (MML)
0-3 dB = easy to mask
4-10 dB = masking may be intrusive
gt 10 dB = difficult to mask
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
bull Audiologist
bull Otolaryngologist
bull Psychologist
bull Psychiatrist
bull Neurologist
bull Pharmacologist
bull Nutritionist
bull TMJ Specialist
bull Physical Therapist
bull Biofeedback Specialist
Tinnitus Management Team
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
bull Medication
bull Perfusions
bull Surgery
bull Stress Management
bull Biofeedback (mirrored)
bull Nutritional Counseling
bull rTMS
Tinnitus patient management
procedures
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
bull ginkgo biloba
bull fish oil omega fatty acids
bull acupuncture
bull hyperbaric treatment
bull magnetotherapy
bull lasertherapy
bull homeopathy
bull naturopathy (like cures like)
bull osteopathy
bull DMSO
bull anticholinergic drugs (glutamic acid)
bull vaso-active drugs and carbogen inhalation
bull baclofen injections
bull electrostimulation
Alternative Approaches
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Tinnitus Therapies
Reduce Contrast Mask Phantom Percept Suppress Hyperactivity Examples
o Maskers o Hearing Aids o ldquoNeuromonicsrdquo o ldquoZenrdquo Fractal tones oldquoSound Curerdquo oldquoCo-ordinated Reset Stimulationrdquo o Cochlear Implants
Reclassify Phantom Percept Reduce Saliency Mitigate Emotional Distress Examples
o Tinnitus Retraining o Neuromonics o Widex Zen Therapy o Antidepressants o Cognitive-behavioral therapy o Mindfulness Based Stress
o Reduction
Disrupt Information Conveyance
Avoid Interference with Audition Examples
o Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS)
Auditory-Striatal-Limbic Connectivity
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Reversing pathological neural activity using
targeted plasticity
bull Several studies have reported that the severity of chronic pain and tinnitus is correlated with the degree of map reorganization in somatosensory and auditory cortex respectively
bull Repeatedly pairing tones with brief pulses of vagus nerve stimulation completely eliminated the physiological and behavioral correlates of tinnitus in noise-exposed rats Improvements persisted for weeks after the end of therapy
bull Pairing release of neuromodulators (such as acetylcholine and norepinephrine) with tones that are distant from the tinnitus frequency reverse the frequency map distortion and the pathological activity patterns associated with tinnitus
Engineer ND Riley JR Seale JD Vrana WA Shetake JA Sudanagunta SP Borland MS
Kilgard MP Nature 2011 Feb 3470(7332)101-4 Epub 2011 Jan 12
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Placebo processing
1 octave notch elsewhere
No notch at tinnitus frequency
Target processing
1 octave notch around
Tinnitus frequency
Same processing on both ears
Okamoto H et al PNAS 20101071207-1210
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
ldquoReasonablerdquo tinnitus patient management
procedures
bull Counseling ndash Reassurance (including placebo)
ndash Education
ndash Cognitive-Behavioral Therapy
bull Sound enrichment ndash Masking or mixing
ndash Amplification
bull Combination ndash Desensitization Habituation (TRT)
ndash Neuromonics acoustic desensitization protocol
ndash Fractal tones
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Big difference between ldquono curerdquo
and ldquono helprdquo
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
bull initiate and facilitate tinnitus
habituation
bull remove perception from patientrsquos
consciousness
Objectives
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Tinnitus Retraining Therapy
bull directive counseling
bull auditory (low level noise)
therapy
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Habituation
bull the process of ignoring (or becoming
accustomed to) a stimulus without
exerting any conscious effort
bull from a psychological perspective it is
defined as the adaptation or decline of
a conditioned response to a stimulus
following repeated exposure to that
stimulus
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Basic assumptions
bull The brain can sort out meaningful
stimuli from those which are not
bull Attention is directed toward
salient or information-bearing
stimuli
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
The Limbic System
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Examples of normal habituation
bull Ring on your finger
bull Clothing
bull Refrigerator humming
bull Rear end (buttocks) in your chair
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
How sensory systems suppress
stimuli
bull Somatosensory
bull Auditory
bull How brain (limbic system) determines
importance of external stimuli
ndash Thunder versus soft unexpected sound
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
bull low level noise interferes with pattern recognition by increasing neuronal activity
bull this makes tinnitus more difficult to detect
bull gradually increasing input could decrease gain over an extended time
bull Some (Jastreboff) suggests 24 hours a day 7 days a week
bull Others (Neuromonics) claim 2-4 hours adequate
Sound enrichment for
desensitization habituation
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Current sound treatments
bull Noise generators
bull Maskers
bull Music
bull Hearing aids (effective in over 60 of cases)
bull Combination instruments
bull Home based
bull CDs (eg Personal Growth Tinnitus Relief Petroff DTM)
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Terminology
bull Masking
bull Partial Masking
bull Mixing
bull Music (unfiltered filtered dynamically
altered fractal tones)
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
The three enemies of tinnitus
bull Excessive noise
bull Silence
bull Fear
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Essential attributes for inducing tinnitus
sensitization (opposite of habituation)
bull Tinnitus is considered noxious
bull Tinnitus may induce fear
bull Tinnitus progression is unpredictable
bull Patient feels helpless (loss of control) and canrsquot
cope
bull Patient is anxious
bull If present engagement if not present
disengagement
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Definition of Cognitive-Behavior
Therapy
The therapeutic effort to modify
maladaptive thoughts and
behaviors by applying
systematic measurable
implementation of strategies
designed to alter unproductive
actions
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Similarities of tinnitus with
pain
bull subjective
bull invisible
bull affected by extraneous
events
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Differences between TRT and
Cognitive Therapies
bull CT is intensive and collaborative designed
for 8-12 weekly sessions and direct testing
of hypotheses
bull Tinnitus remains but coping skills improve
bull TRT uses directive counseling with 6 ndash 8
sessions over 18 month period
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Why hearing aids may help tinnitus patients
bull Greater neural activity allows brain to correct for abnormal reduced inhibition
bull Enriched sound environment may prevent maladaptive cortical reorganization
bull Alter production peripherally andor centrally
bull Reduce contrast to quiet
bull Partially mask tinnitus
bull Fatigue and stress is reduced allowing more resources to be allocated to tinnitus fight
bull All of the above may facilitate habituation
and
bull The majority of tinnitus sufferers have at least some degree of hearing loss
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
A perfect example of an auditory
disorder closely related to stress
Tinnitus
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Influence of noise and stress on probability
of having tinnitus
bull N = 12 166 N with tinnitus) = 2024 (16)
bull Each year of age increased the odds ratio of tinnitus by about 3
bull Men generally showed a higher risk for tinnitus compared with women
bull Exposure to noise and stress were important for the probability and level of discomfort from tinnitus However for the transition from mild to severe tinnitus stress turned out to be more important
bull Reduction of likelihood of tinnitus if noise is removed = 27 if stress is removed =19) if both removed = 42
bull Conclusions Stress management strategies should be included in hearing conservation programs especially for individuals with mild tinnitus who report a high stress load ndash Baigi et al Ear and Hearing 2011 32 6787-789
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
bull Music has been shown to activate the
limbic system and other brain structures
(including the frontal lobe and cerebellum)
and has been shown to produce
physiologic changes associated with
relaxation and stress relief
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Where is music processed
Frontal
Lobe
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
How is music used
bull Home
bull Work
bull Celebrations
bull Advertising
bull Romance
bull Movies
bull Athletic locker rooms
bull Shopping malls
bull Hospitals
bull Therapies
bull Relaxation
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Modes of Delivery
bull Home stereo
bull iPod
bull Neuromonics
bull Hearing aids
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
ldquoRulesrdquo of music and emotions
bull Slow onset long quiet sounds ndash calming
bull Music with a slow tempo (ie near natural heart rate (60 ndash 72 beats per minute) - relaxing
bull Repetition - emotionally satisfying
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Neuromonics
bull a bit of cognitive therapy
bull A bit of TRT
bull Music therapy (for affect and relaxation) and wide band stimulation using a iPod-like processor with Bang and Olufsen earphones
bull Rhythm
bull Hearing instrument algorithm (equal sensation level) for hearing loss compensation
bull 2 stage program
bull expensive
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Neuromonics
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Why canrsquot we just use an iPod
bull Frequency shaping
bull Loudness balance
bull Compression
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Categorical Expectations
bull We donrsquot like the unexpected
bull But certain rules have to be followed
bull Active listening may arouse passive listening may soothe
bull For tinnitus patients active listening may draw attention to the tinnitus passive listening may facilitate habituation
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Selecting the right sounds
Sounds (including music) affects people in
different ways due to inherent learned (and cultural) preferences
Thus it is appropriate to use relaxing background sounds (that activate the parasympathetic division of the autonomic nervous system) and minimize exposure to alerting negative or annoying sounds (that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Considerations
bull For relaxation ndash Music with a rhythm slower than your natural heart rate (72 beats
per minute) is useful to many people
ndash Lower pitches are more calming than higher pitches generally speaking
bull For focus and concentration ndash No distraction
ndash Personal preference
ndash Few emotional tags
bull For tinnitus ndash Active listening (distraction)
ndash Masking (covering up)
ndash Passive listening (habituation desensitization)
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Definition of fractal
bull a rough or fragmented geometric shape
that can be split into parts each of which
is (at least approximately) a reduced-size
copy of the wholerdquo
bull Properties include self-similarity and a
simple and recursive definition
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Fractals in nature
bull Examples include
ndash clouds rivers fault lines mountain ranges
craters snow flakes crystals lightning
cauliflower broccoli blood vessels ocean
waves and DNA
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
bull Fractal tones create a melodic chain of
tones that repeat enough to sound familiar
and follow appropriate rules but vary
enough to not be predictable
bull Fractal technology ensures that no sudden
changes appear in tonality or tempo
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Conclusions of Kochkin et al 2011
bull Of the nine tinnitus treatment methods assessed none were tried by more than 7 of the subjects
bull Treatment methods rated with substantial tinnitus amelioration were hearing aids (34) and music (30)
bull Subjects who had their hearing aids fit by professionals using comprehensive hearing aid fitting protocols are nearly twice as likely to experience tinnitus relief than respondents fit by hearing care professionals using minimalist hearing aid fitting protocols
bull This study confirms that the provision of hearing aids offers substantial benefit to a significant number of people suffering from tinnitus This fact should be more widely acknowledged in both the audiological and medical communities
ndash Kochkin S Tyler R Born J MarkeTrak VIII The Prevalence of
Tinnitus in the United States and the Self-reported Efficacy of Various Treatments Hearing Review 201118(12)10-27
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Disclosure
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Zen
bull An optional listening program in certain (Passion Mind
and Clear) Widex hearing aids that plays adjustable
continuous chime-like tone complexes using fractal
algorithms
bull The chimes are generated based on an understanding of
the properties of music that would be most relaxing
(Robb et al 1995) bull Ability to self select music
bull Tempo near or below resting heart rate (60-72 bpm)
bull Fluid melodic movement
bull Variety of pitches
bull No rapid amplitude changes
bull Element of uncertainty (Beauvous 2007)
bull Passive listening
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
bull Each Zen program can be individually
adjusted to loudness pitch and tempo
preferences
bull The fractal tones (or the noise) should be
audible but relatively soft
bull It should never interfere with
conversational speech
bull The annoyance level of the tinnitus should
just begin to decrease (ie tinnitus can
still be audible)
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Frequency response and amplitude settings are based on in-situ audiogram A filtered broad band noise can be used as a separate program or in combination with the fractal tones Signals are dichotic
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Evidence of effectiveness
bull Sweetow amp Henderson-Sabes The use of acoustic stimuli in tinnitus management JAAA 217 461-473 2010
bull Kuk F Peeters H Lau CL The efficacy of fractal music employed in hearing aids for tinnitus management Hearing Review 201017(10)32-42
bull Herzfeld and Kuk Hearing Review 2011 18(11) 50-55
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
500 1000 2000 4000 8000
0
20
40
60
80
100
Frequency (Hz)
dB
HL
bull14 subjects with severe uncompensated tinnitus 6 non-tinnitus subjects 2 subjects dropped out
bull All tinnitus subjects had been seen at UCSF for tinnitus treatment at least 3 mos prior to the study ndash completed tinnitus counseling and other therapies but were still significantly bothered (average THI entering study = 587) bull All subjects had tinnitus for at least one year and had received no active treatments (including counseling) for at least three months prior to the start of the experiment bull Battery of questionnaires = THI TRQ stress annoyance and relaxation measures
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Study Questions
bull Would fractal tones (andor noise)
delivered through hearing aids be
ndash Perceived as relaxing to tinnitus patients
ndash Reduce short term tinnitus annoyance in the
lab
ndash Lower subjective tinnitus handicap and
reaction scores in a 6 month field trial
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Aqua Coral Lavender Green
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Relaxation ratings
0
1
2
3
4
5
Rela
xa
tio
n R
ati
ng
Zen alone Zen+Master Zen+Master+Noise
1 ndash very relaxing 2 ndash somewhat relaxing 3 ndash neither relaxing nor stressful
4 ndash somewhat tensing 5 ndash very tensing
More Relaxed
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
-1
0
1
2
3
4
5
6
Tin
nit
us
An
no
ya
nc
e R
ati
ng
Unaided Master Aqua Coral Lavender Green Noise
0 ndash no annoyance 1 ndash just slightly annoying 2 ndash mildly annoying 3- moderately annoying
4 ndash very annoying 5 ndash extremely annoying 6 ndash worst possible annoyance
Less Annoying
Tinnitus annoyance
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Tinnitus Handicap Inventory
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Herzfield and Kuk 2011 (48 subjects receiving counseling plus Zen
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Summary of findings
bull Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
bull Both fractal tones and noise reduced
tinnitus annoyance but the fractal
tones were preferred by subjects for
longer term use
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Disclosure
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Widex Zen Therapy
bull an integrated program addressing all 3 major
components of tinnitus distress auditory
attention and emotion
bull many patients will be adequately served by
counseling and sound therapy (hearing aids
fractal tones or noise) alone
bull patients with nnegative reactions treated
with a comprehensive program integrating
cognitive-behavioral concepts and relaxation
exercises along with the counseling and
acoustic tools
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
The overall objective of Widex
Zen Therapyhellip
bull is to ensure that the tinnitus does
not negatively impact the patients
quality of life
bull it is not designed to be a cure or
to suppress tinnitus (though it
sometimes produces that effect)
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Components
1 Counseling to educate the patient and assist the
limbic system to alter its negative interpretation of
the tinnitus via cognitive and behavioral
intervention
2 Amplification (binaurally when appropriate) to
stimulate the ears and brain in order to discourage
increased in central activity (overcompensation)
and maladaptive cortical reorganization
3 Fractal tones binaurally delivered to the patient in a
discreet inconspicuous and convenient manner
designed to both relax and provide acoustic
stimulation
4 Relaxation strategy program highlighted by
behavioral exercises and sleep management
strategies
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Counseling
bull Instructional
bull Adjustment-based
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Counseling
bull Instructional counseling helps educate the patient about aspects of the tinnitus itself For example it addresseshelliphelliphelliphellip
ndash the basic anatomy and physiology of the auditory (and central nervous) system
ndash why the tinnitus is present (particularly when it is a normal consequence of having a hearing loss)
ndash what the logical course of the tinnitus might be
ndash how the limbic system affects the tinnitus perception and how the patientrsquos reaction impacts the ability to cope with or habituate to the tinnitus
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Adjustment based
counselinghellip bull Helps the patient recognize aspects about how
the tinnitus is affecting him or her and the cognitive and behavioral implications It is designed to
bull address the emotional sequelae of tinnitus including fear anxiety and depression
bull identify and correct maladaptive thoughts and behaviors
bull understand the relationship between tinnitus stress fear behaviors thoughts and quality of life
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Cognitive behavioral interventionhellip
bull is designed to identify the unwanted thoughts and behaviors hindering natural habituation challenge their validity and replace them with alternative and logical thoughts and behaviors
bull the objective is to remove inappropriate beliefs anxieties and fears and to help the patient recognize that it is not the tinnitus itself that is producing these beliefs it is the patients reaction (and all reactions are subject to modification)
The basic processes in cognitive-behavioral intervention are
bull identify behaviors and thoughts affected by the tinnitus
bull list maladaptive strategies and cognitive distortions currently employed
bull challenge the patient to identify negative thoughts
bull identify alternate thoughts behaviors and strategies
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger depression anxiety)
Emotional response is the result of the
thoughts not the event (awareness of the
tinnitus) itself
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Some suggestionshellip
bull Ask ldquowhat will make this encounter or
therapy successful in your mindrdquo
bull Remember that tinnitus patient
management is a journey remind patients
of the ups and downs to be expected
bull Tell patient that 1st thought upon
recognizing tinnitus should behellip
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Relaxation Exercises
bull Progressive Muscle Relaxation
bull Deep breathing
bull Guided imagery
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
General suggestions for the relaxation
exercises
bull Perform the exercises while sitting in a
comfortable chair in a quiet place with no distractions
bull Do the exercises while listening to the Zen tones but if you are too distracted turn off the tones
bull Remove your shoes and wear loose comfortable clothing
bull Dont worry if you fall asleep
bull After finishing the exercise close your eyes relax for a few minutes breathe deeply and rise up slowly
bull NOTE IF YOU HAVE MEDICAL CONDITIONS THAT MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Progressive Muscle Relaxation (PMR)
bull PMR consists of alternating deliberately tensing muscle groups and then releasing the tension Focus on the muscle group for example your right foot Then inhale and simply tighten the muscles as hard as you can for about 8 seconds Try to only tense the muscle group that you are concentrating on Feel the tension Then release by suddenly letting go Let the tightness and pain flow out of the muscles while you slowly exhale Focus on the difference between tension and relaxation
bull head (facial grimace)
bull neck and shoulders
bull chest
bull stomach
bull right upper arm
bull right hand
bull left upper arm
bull left hand
bull buttocks
bull right upper leg
bull right foot
bull left upper leg
bull left foot
bull Relax for about 10-15 seconds and repeat the progression The entire exercise should take about 5 minutes
bull DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Deep breathing
bull This is the simplest of the relaxation procedures It simply requires you to follow the five suggestions above and to add deep rhythmic breathing Specifically you should complete the following cycle 20 times
bull Exhale completely through your mouth
bull Inhale through your nose for four seconds (count one thousand one one thousand two one thousand three one thousand four)
bull Hold your breath for seven seconds
bull Exhale through your mouth for eight seconds
bull Repeat the cycle 20 times
bull The entire process will take approximately 7 minutes
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Sleep suggestions (partial list)
bull Maintain a standard bedtime for each day
bull Set your alarm for the same time each day
bull Walk or exercise for ten minutes a day but not right before going to sleep
bull Set thermostat for a comfortable bedroom temperature
bull Use a fan or white noise machine to interfere with your tinnitus
bull Close your curtainsdrapes and maintain a bedroom dark enough to sleep
bull Change the number of pillows you use This also may impact somatic contributors to tinnitus
bull Dont watch TV eat or read in bed Use your bed for sleep and sex
bull Sleep on your back or on your side try to avoid sleeping on your stomach
bull Take prescription medicines as directed but only if required
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
The manualhelliphellip
helliphelps establish realistic time-based
expectations provides methods of
assessing progress and creates a follow
up schedule
In addition the information is
demonstrated with the use of case
examples
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Improvement
bull Reduction in the number of episodes of
awareness
bull Increase in the intervals between episodes of
awareness
bull Increase in quality of life
bull Not necessarily a reduction in perceived
loudness
bull Effect may NOT be immediate
bull Establish realistic time-based expectations
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Counsel about the following
bull Tinnitus is not unique to that one patient
bull Tinnitus is not a sign of insanity or grave illness
bull Tinnitus may be a ldquonormalrdquo consequence of hearing loss
bull Tinnitus probably is not a sign of impending deafness
bull There is no evidence to suggest the tinnitus will get worse
bull Tinnitus does not have to result in a lack of control
bull Patients who can sleep can best manage their tinnitus
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Counsel about the following
bull Tinnitus is real and not imagined
bull Tinnitus may be permanent
bull Reaction to the tinnitus is the source of the problem
bull Reaction to the symptom is manageable and
subject to modification
bull If significance and threat is removed habituation or
gating of attention can be achieved
bull Stay off the internet
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Conclusions
bull Tinnitus patients with hearing loss may best be served by amplification that incorporates low compression thresholds a broad frequency response and flexible options for acoustic stimuli
bull Tailor the therapy to the patientrsquos functional and financial needs
bull Sound therapy without counseling is not likely to work
Thanks for listening
robertsweetowucsfedu
Thanks for listening
robertsweetowucsfedu
